Practice questions III Lung and pleural tumors

Practice questions III

Lung and pleural tumors

© Jun Wang, MD, PhD

 

1. Use this case and this image for next three questions. A 75-year-old woman presents with non-productive cough and a 15 lb weight loss in the past 6 months. She does not have fever or chest pain. She has a history of clear cell type renal cell carcinoma at age 57 and was treated with left nephrectomy. Her past medical history is otherwise unremarkable. She does not smoke cigarette nor drink alcohol. Radiologic examination reveals a 2.5 cm lesion in the right middle lobe. An image of the biopsy is shown. There are foci of necrosis with neutrophils. What is most likely the diagnosis? 
 (Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)
 
A. Abscess
B. Adenocarcinoma
C. Metastatic renal cell carcinoma
D. Small cell carcinoma
E. Squamous cell carcinoma
 
2. A 75-year-old woman presents with non-productive cough and a 15 lb weight loss in the past 6 months. She does not have fever or chest pain. She has a history of clear cell type renal cell carcinoma at age 57 and was treated with left nephrectomy. Her past medical history is otherwise unremarkable. She does not smoke cigarette nor drink alcohol. Radiologic examination reveals a 2.5 cm lesion in the right middle lobe. An image of the biopsy is shown. There are foci of necrosis with neutrophils. What marker is most likely positive for this lesion?
(Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)

 

A. Calretinin
B. Chromogranin
C. p63
D. TTF-1
E. Vimentin

3. A 75-year-old woman presents with non-productive cough and a 15 lb weight loss in the past 6 months. She does not have fever or chest pain. She has a history of clear cell type renal cell carcinoma at age 57 and was treated with left nephrectomy. Her past medical history is otherwise unremarkable. She does not smoke cigarette nor drink alcohol. Radiologic examination reveals a 2.5 cm lesion in the right middle lobe. An image of the biopsy is shown. There are foci of necrosis with neutrophils. What molecular test should be performed next? 
(Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)
 
A. ALK and EGFR
B. BHD and VHL
C. Mismatch repair (MMR) genes
D. NF1 and NF2
E. TSC1 and TSC2

 
4. Use this case and this image for next three questions. A 65-year-old man presents with anorexia and weakness for 2 weeks. He was diagnosed with colon intramucosal adenocarcinoma at age 52 and was treated with endoscopic mucosal resection. The resection margins were negative for malignancy per pathology report. He has a history of hypertension and COPD. He smoked 1 and a half pack cigarette per day for 30 years and quitted smoking 10 years ago, after his COPD was diagnosed. He occasionally drinks wine. Physical examination is unremarkable. Laboratory tests reveals a hemoglobin of 11.5 g/dl (14-18 g/dl), a serum calcium at 11.7 mg/dl (normal 8.6-11.2 mg/dl). Other lab results are within normal range. Chest CT scan reveal a 3.5 cm mass at left lower lobe, near hilum. Left hilar lymphadenopathy is noted as well. Image of his biopsy is shown. What is most likely the diagnosis? 
(Image source and license: https://www.flickr.com/photos/pulmonary_pathology/3923394574/in/photostream/)
A. Carcinoid
B. Large cell carcinoma
C. Metastatic colonic adenocarcinoma
D. Small cell carcinoma 
E. Squamous cell carcinoma

5. A 65-year-old man presents with anorexia and weakness for 2 weeks. He was diagnosed with colon intramucosal adenocarcinoma at age 52 and was treated with endoscopic mucosal resection. The resection margins were negative for malignancy per pathology report. He has a history of hypertension and COPD. He smoked 1 and a half pack cigarette per day for 30 years and quitted smoking 10 years ago, after his COPD was diagnosed. He occasionally drinks wine. Physical examination is unremarkable. Laboratory tests reveals a hemoglobin of 11.5 g/dl (14-18 g/dl), a serum calcium at 11.7 mg/dl (normal 8.6-11.2 mg/dl). Other lab results are within normal range. Chest CT scan reveal a 3.5 cm mass at left lower lobe, near hilum. Left hilar lymphadenopathy is noted as well. Image of his biopsy is shown. What is marker is likely to be positive in this tumor?
(Image source and license: https://www.flickr.com/photos/pulmonary_pathology/3923394574/in/photostream/)

 
A. Chromogranin
B. CK20
C. p63
D. TTF-1
E. WT-1

6. A 65-year-old man presents with anorexia and weakness for 2 weeks. He was diagnosed with colon intramucosal adenocarcinoma at age 52 and was treated with endoscopic mucosal resection. The resection margins were negative for malignancy per pathology report. He has a history of hypertension and COPD. He smoked 1 and a half pack cigarette per day for 30 years and quitted smoking 10 years ago, after his COPD was diagnosed. He occasionally drinks wine. Physical examination is unremarkable. Laboratory tests reveals a hemoglobin of 11.5 g/dl (14-18 g/dl), a serum calcium at 11.7 mg/dl (normal 8.6-11.2 mg/dl). Other lab results are within normal range. Chest CT scan reveal a 3.5 cm mass at left lower lobe, near hilum. Left hilar lymphadenopathy is noted as well. Image of his biopsy is shown. What is most likely the cause of his elevated serum calcium?
(Image source and license: https://www.flickr.com/photos/pulmonary_pathology/3923394574/in/photostream/)


A. Calcium-sensing receptor mutation
B. Ectopic production of parathyroid hormone related protein
C. Primary hyperparathyroidism
D. Secondary hyperparathyroidism
E. Vitamin D toxicity

7. A 65-year-old man presents with anorexia and weakness for 2 weeks. He was diagnosed with colon intramucosal adenocarcinoma at age 52 and was treated with endoscopic mucosal resection. The resection margins were negative for malignancy per pathology report. He has a history of hypertension and COPD. He smoked 1 and a half pack cigarette per day for 30 years and quitted smoking 10 years ago, after his COPD was diagnosed. He occasionally drinks wine. Physical examination is unremarkable. Laboratory tests reveals a hemoglobin of 11.5 g/dl (14-18 g/dl), a serum calcium at 11.7 mg/dl (normal 8.6-11.2 mg/dl). Other lab results are within normal range. Chest CT scan reveal a 3.5 cm mass at left lower lobe, near hilum. Left hilar lymphadenopathy is noted as well. Image of his biopsy is shown. What is most important risk factor for this lesion?
(Image source and license: https://www.flickr.com/photos/pulmonary_pathology/3923394574/in/photostream/)


A. Alcohol usage
B. Asbestos exposure
C. Cigarette smoking
D. EGFR mutation
E. UV light

 
8. Use this case and this image for next four questions. A 61-year-old woman presents with double vision for 2 weeks. She has had dry cough and a 15lb weight loss for the last three months. Her past medical history is unremarkable. She does not smoke cigarette nor drink alcohol. Upon physical examination, her right pupil is 4 mm in diameter, and left pupil 6 mm in diameter. Her vision field and eye movement are normal. Radiologic examination reveals a 2 cm solid mass at the apex of right upper lobe. No other abnormalities are seen. Image of biopsy of the mass is shown. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for CK5/6, vimentin and synaptophysin. What is the most likely diagnosis? 
(Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons) 
A. Adenocarcinoma of lung
B. Large cell carcinoma
C. Mesothelioma, epithelioid type
D. Small cell carcinoma
E. Squamous cell carcinoma

9. A 61-year-old woman presents with double vision for 2 weeks. She has had dry cough and a 15lb weight loss for the last three months. Her past medical history is unremarkable. She does not smoke cigarette nor drink alcohol. Upon physical examination, her right pupil is 4 mm in diameter, and left pupil 6 mm in diameter. Her vision field and eye movement are normal. Radiologic examination reveals a 2 cm solid mass at the apex of right upper lobe. No other abnormalities are seen. Image of biopsy of the mass is shown. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for CK5/6, vimentin and synaptophysin. What additional test needs to be performed? 
(Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)


A. Chromogranin stain
B. EB virus studies
C. Molecular studies for EGFR mutation
D. Sputum Gram stain, culture and sensitivity
E. WT1 stain

10. A 61-year-old woman presents with double vision for 2 weeks. She has had dry cough and a 15lb weight loss for the last three months. Her past medical history is unremarkable. She does not smoke cigarette nor drink alcohol. Upon physical examination, her right pupil is 4 mm in diameter, and left pupil 6 mm in diameter. Her vision field and eye movement are normal. Radiologic examination reveals a 2 cm solid mass at the apex of right upper lobe. No other abnormalities are seen. Image of biopsy of the mass is shown. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for CK5/6, vimentin and synaptophysin. What is most likely causing her eye symptoms?(Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)


A. Autoantibody against postsynaptic acetylcholine receptor
B. Autoantibody against presynaptic voltage-gated calcium channels
C. Local irritation of sympathetic nerve supply by the lung lesion
D. Metastatic tumor disrupt cranial nerve III
E. Metastatic tumor to right orbit

11. A 61-year-old woman presents with double vision for 2 weeks. She has had dry cough and a 15lb weight loss for the last three months. Her past medical history is unremarkable. She does not smoke cigarette nor drink alcohol. Upon physical examination, her right pupil is 4 mm in diameter, and left pupil 6 mm in diameter. Her vision field and eye movement are normal. Radiologic examination reveals a 2 cm solid mass at the apex of right upper lobe. No other abnormalities are seen. Image of biopsy of the mass is shown. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for CK5/6, vimentin and synaptophysin. Abnormality of what gene is likely seen?(Image credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)


A. BHD
B. EGFR
C. NF1
D. VHL
E. WT-1 


12. Use this case and image for next two questions. A 55-year-old man presents with worsening dry cough and intermittent left chest pain for 3 months. He has lost 10 lb since then. He does not have fever, chills and hemoptysis. His past medical history is unremarkable. He has a 30-pack-year history of cigarette smoking and drinks 1-2 cups of liquor per day. He works as a construction worker for 40 years. Physical examination reveals no significant abnormalities except pallor skin. His CBC reveal a hemoglobin of 9.5 g/dl (normal 14-18 g/dl) and a white count at 13.5 x 109/L (normal 4.7 -10.5 x 109/L). Chest CT scan reveal a 3.1 cm mass of left lower lobe, very close to the posterior edge. The mass is resected, and an image of the microscopic examination is shown. Per immunohistochemistry studies, these atypical cells are positive for pan-cytokeratin, but negative for chromogranin, CD45, CD56, p63, TTF-1 and calretinin. What is the most likely diagnosis?
(Image credit: The Armed Forces Institute of Pathology (AFIP), Public domain, via Wikimedia Commons)

A. Large cell carcinoma
B. Hodgkin lymphoma
C. Mesothelioma
D. Small cell carcinoma
E. Squamous cell carcinoma

13. A 55-year-old man presents with worsening dry cough and intermittent left chest pain for 3 months. He has lost 10 lb since then. He does not have fever, chills and hemoptysis. His past medical history is unremarkable. He has a 30-pack-year history of cigarette smoking and drinks 1-2 cups of liquor per day. He works as a construction worker for 40 years. Physical examination reveals no significant abnormalities except pallor skin. His CBC reveal a hemoglobin of 9.5 g/dl (normal 14-18 g/dl) and a white count at 13.5 x 109/L (normal 4.7 -10.5 x 109/L). Chest CT scan reveal a 3.1 cm mass of left lower lobe, very close to the posterior edge. The mass is resected, and an image of the microscopic examination is shown. Per immunohistochemistry studies, these atypical cells are positive for pan-cytokeratin, but negative for chromogranin, CD45, CD56, p63, TTF-1 and calretinin. What risk factor is the most likely associated with this lesion?
(Image credit: The Armed Forces Institute of Pathology (AFIP), Public domain, via Wikimedia Commons)


A. Alcohol usage
B. Asbestose exposure
C. Cigarette smoking
D. EB virus infection
E. EGFR mutation


14. Use this case and image for next three questions. A 59-year-man presents with fatigue, double vision and night sweating for 1 month. He has lost 15 lb in the three months. His past medical history is significant for chronic lymphocytic leukemia, hypertension and type II diabetes. He has a 40 pack-year history of cigarette smoking. His vital signs are within normal range except a blood pressure of 150/90 mm Hg. Physical examination reveals mild bilateral eyelid ptosis and reduced muscle strength around shoulder. His laboratory test results are within normal ranges except a hemoglobin of 8.5 g/dl (14-18 g/dl). CT scan reveals a 3.5 cm mass in the hilar area of right lung. Mediastinal lymphadenopathy is noted. Image of biopsy of this mass is shown. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What is the most likely diagnosis of this mass?
(CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons)
 
A. Diffuse large B cell lymphoma
B. Hodgkin lymphoma
C. Small cell carcinoma
D. Small lymphocytic lymphoma
E. Squamous cell carcinoma

15. A 59-year-man presents with fatigue, double vision and night sweating for 1 month. He has lost 15 lb in the three months. His past medical history is significant for chronic lymphocytic leukemia, hypertension and type II diabetes. He has a 40 pack-year history of cigarette smoking. His vital signs are within normal range except a blood pressure of 150/90 mm Hg. Physical examination reveals mild bilateral eyelid ptosis and reduced muscle strength around shoulder. His laboratory test results are within normal ranges except a hemoglobin of 8.5 g/dl (14-18 g/dl). CT scan reveals a 3.5 cm mass in the hilar area of right lung. Mediastinal lymphadenopathy is noted. Image of biopsy of this mass is shown. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What additional marker is likely to be positive for these cells?
(CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons)


A. CD20
B. CD99
C. p63
D. Synaptophysin
E. WT-1

 
16. A 59-year-man presents with fatigue, double vision and night sweating for 1 month. He has lost 15 lb in the three months. His past medical history is significant for chronic lymphocytic leukemia, hypertension and type II diabetes. He has a 40 pack-year history of cigarette smoking. His vital signs are within normal range except a blood pressure of 150/90 mm Hg. Physical examination reveals mild bilateral eyelid ptosis and reduced muscle strength around shoulder. His laboratory test results are within normal ranges except a hemoglobin of 8.5 g/dl (14-18 g/dl). CT scan reveals a 3.5 cm mass in the hilar area of right lung. Mediastinal lymphadenopathy is noted. Image of biopsy of this mass is shown. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What is the most likely cause of his reduced muscle strength?
(CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons)


A. Autoantibody against acetylcholine receptor
B. Diabetic neuropathy
C. Irritation of sympathetic nerve supply
D. Muscular atrophy
E. Voltage-gated channel dysfunction


17. Use this case and this image for next two questions. A 65-year-old man presents with slowing growing left anterior neck mass for 3 month and progressive facial swelling, lightheadedness, blurred vision and syncope for 2 weeks. He does not have history of heart disease or seizures. He has had a 25 lb weight loss in one year. He does not smoke cigarette nor drink alcohol. Physical examination reveals distended superficial jugular veins and moderate edema of both arms, a 2.5 cm solid non mobile nodules at right supraclavicular area. CT scan reveals a 3 cm mass at right upper lobe and upper mediastinal lymphadenopathy. Image of the supraclavicular lesion is shown. What is the diagnosis concerning the lymph node findings?
(Image credit: Nephron, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)

A. Acute lymphadenitis
B. Diffuse large B cell lymphoma
C. Hodgkin lymphoma
D. Metastatic lung adenocarcinoma
E. Metastatic squamous cell carcinoma

18. A 65-year-old man presents with slowing growing left anterior neck mass for 3 month and progressive facial swelling, lightheadedness, blurred vision and syncope for 2 weeks. He does not have history of heart disease or seizures. He has had a 25 lb weight loss in one year. He does not smoke cigarette nor drink alcohol. Physical examination reveals distended superficial jugular veins and moderate edema of both arms, a 2.5 cm solid non mobile nodules at right supraclavicular area. CT scan reveals a 3 cm mass at hilar area and upper mediastinal lymphadenopathy. Image of the supraclavicular lesion biopsy is shown. What is causing the patient’s presentation of facial swelling?
(Image credit: Nephron, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)


A. Acute inflammation
B. Compression of superior vena cava
C. Congestive heart failure
D. Diffuse nonspecific chronic inflammation of subcutaneous tissue
E. Obstruction of lymph by metastatic tumor cells
 
 
19. Use this case and this image for next two questions. A 71-year-old man presents with left chest pain, cough, weakness and shortness of breath for 2 months. His past medical history is significant for type 2 diabetes and chronic obstructive pulmonary disease. He is a retired city subway system maintenance worker after working for over 45 years. He has a 40 pack year history of cigarette smoking, but quitted after the diagnosis of COPD at age 55. He drinks a glass of wine each day. Physical examination reveals scattered crackles bilaterally. CT scan reveals a 2.5 cm left lower lobe mass at the anterior edge. Image of the mass biopsy is shown. Per immunohistochemistry studies, these cells are positive for CK5/6 and calretinin, but negative for TTF-1. What is the diagnosis?
(Image Credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)

A. Adenocarcinoma
B. Large cell carcinoma
C. Mesothelioma
D. Small cell carcinoma
E. Squamous cell carcinoma

20. A 71-year-old man presents with left chest pain, cough, weakness and shortness of breath for 2 months. His past medical history is significant for type 2 diabetes and chronic obstructive pulmonary disease. He is a retired city subway system maintenance worker after working for over 45 years. He has a 40 pack year history of cigarette smoking, but quitted after the diagnosis of COPD at age 55. He drinks a glass of wine each day. Physical examination reveals scattered crackles bilaterally. CT scan reveals a 2.5 cm left lower lobe mass at the anterior edge. Image of the mass biopsy is shown. Per immunohistochemistry studies, these cells are positive for CK5/6 and calretinin, but negative for TTF-1. What is most likely associated with this lesion?
(Image Credit: Yale Rosen from USA, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons)


A. Alcohol
B. Asbestosis
C. Cigarette smoking
D. Hyperglycemia
E. KRAS mutation

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