Practice questions Lung and pleural tumors

Practice questions II, Lung and pleural tumors

© Jun Wang, MD, PhD

1. Use this case for next two questions. A 69-year-old woman presents with non-productive cough for 3 months. She has a history of stage II sigmoid colon cancer 5 month ago, and was treated with surgery and chemotherapy. She just started a cycle of chemotherapy 1 week ago. She has a 30 year 1 pack per day smoking history. She does not drink alcohol. Radiologic examination reveal a 1.5 cm lesion at the right hilum. Biopsy of the lesion reveal cords and nests with irregular contours composed of cells with large amount eosinophilic cytoplasm and markedly atypical nuclei. Intercellular bridges and squamous pearls are seen. There are foci of necrosis with neutrophils. What is most likely the diagnosis?

A. Abscess

B. Adenocarcinoma

C. Metastatic colon cancer

D. Small cell carcinoma

E. Squamous cell carcinoma

2. A 69-year-old woman presents with non-productive cough for 3 months. She has a history of stage II sigmoid colon cancer 5 month ago, and was treated with surgery and chemotherapy. She just started a cycle of chemotherapy 1 week ago. She has a 30 year 1 pack per day smoking history. She does not drink alcohol. Radiologic examination reveal a 1.5 cm lesion at the right hilum. Biopsy of the lesion reveal cords and nests with irregular contours composed of cells with large amount eosinophic cytoplasm and markedly atypical nuclei. Intercellular bridges and squamous pearls are seen. There are foci of necrosis with neutrophils. What marker is most likely positive for this lesion?

A. Calretinin

B. Chromogranin

C. CK20

D. p63

E. TTF-1

3. Use this case for next four questions. A 55-year-old woman presents with anorexia and weakness for 2 weeks. Her past medical history is unremarkable. She has a history of smoking cigarette 1 and a half pack per day for 40 years. She occasionally drinks wine. Physical examination reveals a 1.2 cm firm nodule at the left supraclavicular area. Her laboratory tests reveals a serum calcium at 13.1 mg/dl (normal 8.6-11.2 mg/dl), alkaline phosphate at 474 U/l (normal 60-160). Her lab tests are otherwise within normal ranges. Chest CT scan reveal a 3-cm centrally located solid mass at left lower lobe and left hilar lymphadenopathy. Biopsy of the supraclavicular nodule reveal a lymph node containing atypical cells with abundant eosinophilic cytoplasma and markedly irregular nuclei. Intercellular bridges and squamous pearls are seen. Whole body bone scan is negative for malignant changes. What is most likely the diagnosis for the lymph node findings?

A. Acute lymphadenitis

B. Chronic lymphadenitis

C. Hodgkin lymphoma

D. Metastatic adenocarcinoma

E. Metastatic squamous cell carcinoma

4. A 55-year-old woman presents with anorexia and weakness for 2 weeks. Her past medical history is unremarkable. She has a history of smoking cigarette 1 and a half pack per day for 40 years. She occasionally drinks wine. Physical examination reveals a 1.2 cm firm nodule at the left supraclavicular area. Her laboratory tests reveals a serum calcium at 13.1 mg/dl (normal 8.6-11.2 mg/dl), alkaline phosphate at 474 U/l (normal 60-160). Her lab tests are otherwise within normal ranges. Chest CT scan reveal a 3-cm centrally located solid mass at left lower lobe and left hilar lymphadenopathy. Biopsy of the supraclavicular nodule reveal a lymph node containing atypical cells with abundant eosinophilic cytoplasma and markedly irregular nuclei. Intercellular bridges and squamous pearls are seen. Whole body bone scan is negative for malignant changes. What is most likely the diagnosis for the lung findings?

A. Abscess

B. Adenocarcinoma

C. Hodgkin lymphoma

D. Small cell carcinoma

E. Squamous cell carcinoma

5. A 55-year-old woman presents with anorexia and weakness for 2 weeks. Her past medical history is unremarkable. She has a history of smoking cigarette 1 and a half pack per day for 40 years. She occasionally drinks wine. Physical examination reveals a 1.2 cm firm nodule at the left supraclavicular area. Her laboratory tests reveals a serum calcium at 13.1 mg/dl (normal 8.6-11.2 mg/dl), alkaline phosphate at 474 U/l (normal 60-160). Her lab tests are otherwise within normal ranges. Chest CT scan reveal a 3-cm centrally located solid mass at left lower lobe and left hilar lymphadenopathy. Biopsy of the supraclavicular nodule reveal a lymph node containing atypical cells with abundant eosinophilic cytoplasma and markedly irregular nuclei. Intercellular bridges and squamous pearls are seen. Whole body bone scan is negative for malignant changes. What marker is most likely expressed by the lung lesion?

A. CD30

B. Chromogranin

C. p63

D. TTF-1

E. WT-1

6. A 55-year-old woman presents with anorexia and weakness for 2 weeks. Her past medical history is unremarkable. She has a history of smoking cigarette 1 and a half pack per day for 40 years. She occasionally drinks wine. Physical examination reveals a 1.2 cm firm nodule at the left supraclavicular area. Her laboratory tests reveals a serum calcium at 13.1 mg/dl (normal 8.6-11.2 mg/dl), alkaline phosphate at 474 U/l (normal 60-160). Her lab tests are otherwise within normal ranges. Chest CT scan reveal a 3-cm centrally located solid mass at left lower lobe and left hilar lymphadenopathy. Biopsy of the supraclavicular nodule reveal a lymph node containing atypical cells with abundant eosinophilic cytoplasma and markedly irregular nuclei. Intercellular bridges and squamous pearls are seen. Whole body bone scan is negative for malignant changes. What is most likely causing her elevated serum calcium?

A. Active vitamin D produced by Hodgkin lymphoma

B. Ectopic production of parathyroid hormone related protein

C. Metastatic cancer to bones

D. Secondary hyperparathyroidism

E. Vitamin D toxicity

7. Use this case for next four questions. A 64-year-old woman presents with right eyelid droop for 2 weeks. She has had dry cough and a 15lb weight loss for the last three weeks. She has a history of renal cell carcinoma 10 years ago and was treated with total nephrectomy. Her past medical history is otherwise unremarkable. She is a vegetarian and 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 suprahilar region of right upper lobe. No other abnormalities are seen. Biopsy of the mass reveal irregular cords of atypical cells with vague glandular formation, in a fibrotic background. These cells have nuclei with markedly variable size, shape and staining pattern. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for WT1, vimentin and synaptophysin. What is the most likely diagnosis?

A. Adenocarcinoma of lung

B. Hodgkin lymphoma

C. Metastatic renal cell carcinoma

D. Small cell carcinoma

E. Squamous cell carcinoma

8. A 64-year-old woman presents with right eyelid droop for 2 weeks. She has had dry cough and a 15lb weight loss for the last three weeks. She has a history of renal cell carcinoma 10 years ago and was treated with total nephrectomy. Her past medical history is otherwise unremarkable. She is a vegetarian and 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 suprahilar region of right upper lobe. No other abnormalities are seen. Biopsy of the mass reveal irregular cords of atypical cells with vague glandular formation, in a fibrotic background. These cells have nuclei with markedly variable size, shape and staining pattern. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for WT1, vimentin and synaptophysin. What test need to be performed next?

A. Chromogranin stain

B. Colloid iron stain

C. EB virus studies

D. Molecular studies for EGFR mutation

E. Sputum Gram stain, culture and sensitivity

9. A 64-year-old woman presents with right eyelid droop for 2 weeks. She has had dry cough, and a 15lb weight loss for the last three weeks. She has a history of renal cell carcinoma 10 years ago and was treated with total nephrectomy. Her past medical history is otherwise unremarkable. She is a vegetarian and 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 suprahilar region of right upper lobe. No other abnormalities are seen. Biopsy of the mass reveal irregular cords of atypical cells with vague glandular formation, in a fibrotic background. These cells have nuclei with markedly variable size, shape and staining pattern. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for WT1, vimentin and synaptophysin. What is most likely causing her eye symptoms?

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

10. A 64-year-old woman presents with right eyelid droop for 2 weeks. She has had dry cough, and a 15lb weight loss for the last three weeks. She has a history of renal cell carcinoma 10 years ago and was treated with total nephrectomy. Her past medical history is otherwise unremarkable. She is a vegetarian and 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 suprahilar region of right upper lobe. No other abnormalities are seen. Biopsy of the mass reveal irregular cords of atypical cells with vague glandular formation, in a fibrotic background. These cells have nuclei with markedly variable size, shape and staining pattern. Per immunohistochemistry studies, these cells are positive for CK7 and TTF-1, but negative for WT1, vimentin and synaptophysin. Abnormality of what gene is likely seen?

A. BHD

B. EGFR

C. NF1

D. VHL

E. WT-1

11. A 59-year-old man presents with worsening dry cough and chest pain for 3 months. He has lost 10 lb since then. He denies fever, chills and hemoptysis. His past medical history is unremarkable. He has a 40-pack-year history of cigarette smoking and regularly drinks beers 3 to 5 cans per day. He works as a construction worker for 40 years. Physical examination reveals tachypneac, bilateral rhonchi and diminished breath sounds in left side. Significant laboratory test results include a hemoglobin at 8 g/dl (normal 13-18 g/dl), white count at 13.5 x 10⁹/L (normal 4.7 -10.5 x 10⁹/L) with left shift, ALT 148 IU/L (normal 7-56 U/L), AST 152 U/L (normal 10-40 U/L). His renal functions are normal. Chest X-ray reveal left lower lobe consolidation. Chest CT scan reveal a 2.3 cm mass at the central portion of left lower lobe. Biopsy of the mass reveal solid sheets of markedly atypical cells with large irregular nuclei, brisk mitosis and foci of necrosis and neutrophilic infiltration. Giant cells are seen. Per immunohistochemistry studies, these atypical cells are positive for cytokeratin and negative for p63 and TTF-1. What is the most likely diagnosis?

A. Diffuse large B cell lymphoma

B. Large cell carcinoma

C. Hodgkin lymphoma

D. Small cell carcinoma

E. Squamous cell carcinoma

12. Use this case for next two questions. A 63-year-man presents with night sweating, dry cough and worsening right chest pain for 3 weeks. He feels constantly fatigued and has lost 10 lb in the recent month. He has history of COPD diagnosed 2 years ago. He smokes cigarette 1 pack a day for 40 years but quitted after the diagnosis of COPD. Physical examination reveals high pitched sound bilaterally, hypo-resonance in both lung fields and distant heart sound. CT scan reveals a 3.5 cm mass in the hilar area of right lung and mediastinal lymphadenopathy. Biopsy of the mass reveals nests of small to intermediate sized cells with molding nuclei and scant cytoplasm. The nuclei have salt and pepper appearing chromatin. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What is the most likely diagnosis?

A. Diffuse large B cell lymphoma

B. Hodgkin lymphoma

C. Small cell carcinoma

D. Small lymphocytic lymphoma

E. Squamous cell carcinoma

13. A 63-year-man presents with night sweating, dry cough and worsening right chest pain for 3 weeks. He feels constantly fatigued and has lost 10 lb in the recent month. He has history of COPD diagnosed 2 years ago. He smokes cigarette 1 pack a day for 40 years but quitted after the diagnosis of COPD. Physical examination reveals high pitched sound bilaterally, hypo-resonance in both lung fields and distant heart sound. CT scan reveals a 3.5 cm mass in the hilar area of right lung and mediastinal lymphadenopathy. Biopsy of the mass reveals nests of small to intermediate sized cells with molding nuclei and scant cytoplasm. The nuclei have salt and pepper appearing chromatin. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What additional marker is likely to be positive in these cells?

A. CD30

B. Chromogranin

C. Cyclin D1

D. p63

E. WT-1

14. Use this case for next two questions. A 61-year-old woman presents with lightheadedness, blurred vision and syncope. She denies previous history of heart disease or seizures. She has a history stage I colon cancer that was treated with surgery only 5 years ago. She has had progressive neck discomfort, facial swelling for the last 3 months, and a 25 lb weight loss in one year. She denies history of tobacco and alcohol usage. Physical examination reveals distended superficial jugular veins and moderate edema of both arms, as well as a few solid non mobile nodules at right supraclavicular area. CT scan reveals a 3 cm mass at right upper lobe and upper mediastinal lymphadenopathy. Biopsy of the supraclavicular lesions reveal lymph nodes containing atypical epithelial cells forming glandular pattern. Per immunohistochemistry studies, these epithelial cells are positive for CK7 and TTF-1, but negative for CK20. What is the diagnosis concerning the lymph node findings?

A. Acute lymphadenitis

B. Diffuse large B cell lymphoma

C. Metastatic colon adenocarcinoma

D. Metastatic lung adenocarcinoma

E. Metastatic squamous cell carcinoma

15. A 61-year-old woman presents with lightheadedness, blurred vision and syncope. She denies previous history of heart disease or seizures. She has a history stage I colon cancer that was treated with surgery only 5 years ago. She has had progressive neck discomfort, facial swelling for the last 3 months, and a 25 lb weight loss in one year. She denies history of tobacco and alcohol usage. Physical examination reveals distended superficial jugular veins and moderate edema of both arms, as well as a few solid non mobile nodules at right supraclavicular area. CT scan reveals a 3 cm mass at right upper lobe and upper mediastinal lymphadenopathy. Biopsy of the supraclavicular lesions reveal lymph nodes containing atypical epithelial cells forming glandular pattern. Per immunohistochemistry studies, these epithelial cells are positive for CK7 and TTF-1, but negative for CK20. What is causing the patient’s presentation of facial swelling?

A. Acute inflammation

B. Compression of superior vena cava by tumor

C. Congestive heart failure

D. Diffuse nonspecific chronic inflammation of subcutaneous tissue

E. Obstruction of lymph by metastatic tumor cells

16. Use this case for next two questions. A 71-year-old man presents with progressive proximal limb muscle weakness for 3 months. The weakness is initially noted at the legs, followed by arms. He denies fever, night sweating and weight loss. He has a history of COPD, diagnosed 10 years ago. He has a 50 pack year history of cigarette smoking but denies alcohol usage. Physical examination reveals clubbing of digits and weakened deep tendon reflexes, in addition to signs compatible with COPD. No other neurological abnormality is noted. CT scan reveal a 3 cm centrally located mass at right upper lobe. Biopsy of the mass reveals nests of small to intermediate sized cells with molding nuclei and scant cytoplasm. The nuclei have salt and pepper appearing chromatin. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What is the diagnosis?

A. Carcinoid

B. Hodgkin lymphoma

C. Myasthenia gravis

D. Small cell carcinoma

E. Squamous cell carcinoma

17. A 71-year-old man presents with progressive proximal limb muscle weakness for 3 months. The weakness is initially noted at the legs, followed by arms. He denies fever, night sweating and weight loss. He has a history of COPD, diagnosed 10 years ago. He has a 50 pack year history of cigarette smoking but denies alcohol usage. Physical examination reveals clubbing of digits and weakened deep tendon reflexes, in addition to signs compatible with COPD. No other neurological abnormality is noted. CT scan reveal a 3 cm centrally located mass at right upper lobe. Biopsy of the mass reveals nests of small to intermediate sized cells with molding nuclei and scant cytoplasm. The nuclei have salt and pepper appearing chromatin. Per immunohistochemistry studies, the cells are positive for cytokeratin, but negative for CD45. What is causing his muscular weakness?

A. Autoantibody against postsynaptic acetylcholine receptor

B. Autoantibody against presynaptic voltage-gated calcium channels

C. Chronic disease associated anemia

D. Hypercalcemia associated with ectopic production of parathyroid hormone related protein

E. Local irritation of sympathetic nerve supply by the lung lesion

18. A 66-year-old man presents with 15 lb weight loss and vague left chest discomfort for 3 months. He has a history of renal cell carcinoma of right kidney 20 years ago and was treated with nephrectomy. He has a 40 pack year history of cigarette smoking. He worked at a shipyard for 45 years. Radiologic examination reveal multiple nodules at the periphery of his right lung, in mid and lower lobes. No pleural thickening is noted. Biopsy of the nodules reveal nests of slightly atypical cells with clear cytoplasm, surrounded by fine vasculatures. Per immunohistochemistry studies, these cells are positive for pan-cytokeratin and vimentin, but negative for CK7 and TTF-1. What is the most likely diagnosis?

A. Adenocarcinoma of lung

B. Mesothelioma

C. Metastatic renal cell carcinoma

D. Small cell carcinoma

E. Squamous cell carcinoma

19. A 29-year-old man presents with dry cough, hemoptysis and shortness of breath for 3 months. He denies night sweating and weight loss. His past medical history is unremarkable. He does not smoke cigarette nor drinking alcohol. Physical examination reveals reduced breath sound at left upper lung field. CT reveal a 5.2 cm oval mass in the left upper lobe. Biopsy of the mass reveal cords of cells with decent amount of cytoplasm and intermediate sized round to oval nuclei containing salt and pepper pattern chromatin. No necrosis, mitosis nor glandular differentiation is seen. Per immunohistochemistry studies, these cells are positive for cytokeratin and chromogranin. What is the most likely diagnosis?

A. Adenocarcinoma

B. Carcinoid

C. Hodgkin lymphoma

D. Small cell carcinoma

E. Squamous cell carcinoma

20. Use this case for next two questions. A 65-year-old man presents with dyspnea, cough and right-sided chest pain for 1 month. He had a history of COPD diagnosed 10 years ago. He has a 35 pack year history of cigarette smoking but quitted after the diagnosis of COPD. He worked at a shipyard for 45 years. Radiologic examination reveal right pleural effusion and focal pleural thickening. Thoracentesis was performed and cytological examination reveals marked atypical cells that are positive for CK5/6, calretinin, but negative for TTF-1 and CD20. What is the diagnosis?

A. Adenocarcinoma

B. Empyema

C. Mesothelioma

D. Primary effusion lymphoma

E. Squamous cell carcinoma

21. A 65-year-old man presents with dyspnea, cough and right-sided chest pain for 1 month. He had a history of COPD diagnosed 10 years ago. He has a 35 pack year history of cigarette smoking but quitted after the diagnosis of COPD. He worked at a shipyard for 45 years. Radiologic examination reveal right pleural effusion and focal pleural thickening. Thoracentesis was performed and cytological examination reveals marked atypical cells that are positive for CK5/6, WT1, but negative for TTF-1 and CD20. What is the most likely associated with this lesion?

A. Asbestosis

B. Cigarette smoking

C. COPD

D. EB virus

E. Human herpes virus 8

22. A 61-year-old man presents with cough and vague left chest pain for 1 month. He denies fever, chills or weight loss. His medical history is unremarkable. He has a 30 pack year history of cigarette smoking, but denies alcohol usage. He is coal miner for 40 years. Physical examination is unremarkable. CT scan reveal a 2 cm pleural based mass at left lower lobe. No pleural effusion is seen. Biopsy reveal a fibrotic spindle cell growth with foci of hyalinized stroma, with irregularly dilated vessels. No significant atypia is seen. Per immunohistochemistry studies, these spindle cells are positive for CD99, but negative for calretinin, WT1 and cytokeratin. What is the diagnosis?

A. Adenocarcinoma

B. Mesothelioma, sarcomatoid

C. Small cell carcinoma

D. Solitary fibrous tumor

E. Squamous cell carcinoma

Answers

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