Practice questions upper respiratory tumors

Practice questions I

Upper respiratory tumors

© Jun Wang, MD, PhD

1. Use this case for next two questions. A 17-year-old boy from middle east presents with nasal congestion and epistaxis for 2 months. He denies history of fever, nasal discharge, or trauma. He has a history of infectious mononucleosis 2 years ago. His history is otherwise unremarkable. Physical examination identified a 1.2 cm pink mass at the upper lateral wall of his left nasal cavity. The mass has smooth surface. Biopsy of the mass reveal a lesion with benign squamous epithelial lining, and a fibrotic containing irregularly dilated vessels. There are scattered lymphocytic and plasmacytic infiltrate. No cytological atypia is noted in either the endothelium or stroma. What is most likely the diagnosis?

A. Angiofibroma

B. Angiosarcoma

C. Inverted papilloma

D. Nasopharyngeal carcinoma

E. Olfactory neuroblastoma

2. A 17-year-old boy from middle east presents with nasal congestion and epistaxis for 2 months. He denies history of fever, nasal discharge, or trauma. He has a history of infectious mononucleosis 2 years ago. His history is otherwise unremarkable. Physical examination identified a 1.2 cm pink mass at the upper lateral wall of his left nasal cavity. The mass has smooth surface. Biopsy of the mass reveal a lesion with benign squamous epithelial lining, and a fibrotic containing irregularly dilated vessels. There are scattered lymphocytic and plasmacytic infiltrate. No cytological atypia is noted in either the endothelium or stroma. What additional marker is most likely positive for this lesion?

A. Androgen receptor

B. Chromogranin

C. EB virus encoded RNA

D. Estrogen receptor

E. Nuclear protein in testis

3. Use this case for next two questions. A 65-year-old man presents with slowly progressing right side nasal obstruction for 6 months. He has a history of multiple squamous cell carcinomas of skin, that was treated with surgeries for the past 5 years. He has been smoking cigarette 1 and half pack per day for 45 years. He drinks Whiskey a glass a day. Physical examination reveal a right nasal lateral wall mass with lobulated surfaces. No ulceration is seen. CT scan reveal a bulking mass of approximately 7.5 cm in greatest dimension. No invasion to surrounding tissue is noted. Biopsy reveal solid nests of inward growth of cells with slightly pinkish cytoplasm and minimal atypia. No glandular differentiation is seen. Intercellular bridges are identified. Special stains reveal no evidence of EBV infection. What is most likely the diagnosis?

A. Invasive squamous cell carcinoma

B. Inverted papilloma

C. Metastatic squamous cell carcinoma

D. Nasopharyngeal carcinoma

E. NUT midline carcinoma

4. A 65-year-old man presents with slowly progressing right side nasal obstruction for 6 months. He has a history of multiple squamous cell carcinomas of skin, that was treated with surgeries for the past 5 years. He has been smoking cigarette 1 and half pack per day for 45 years. He drinks Whiskey a glass a day. Physical examination reveal a right nasal lateral wall mass with lobulated surfaces. No ulceration is seen. CT scan reveal a bulking mass of approximately 7.5 cm in greatest dimension. No invasion to surrounding tissue is noted. Biopsy reveal solid nests of inward growth of cells with slightly pinkish cytoplasm and minimal atypia. No glandular differentiation is seen. Intercellular bridges are identified. Special stains reveal no evidence of EBV infection. What is most likely associated with this lesion?

A. Alcohol

B. Cigarette smoking

C. EB virus

D. Human papilloma virus

E. Chromosomal abnormality associated with nuclear protein in testis

5. A 71-year-old man presents with persistent headache and intermittent epistaxis for 4 months. He has a history of chronic lymphocytic leukemia for 4 years, and is currently being followed up. He has been smoking cigarette a pack a day for 50 years. Physical examination does not reveal significant abnormalities. CT scan reveal a mass at the right superior nasopharynx, with extension into right maxillary sinus wall. Biopsy of the mass reveal solid nests of small to intermediate sized cells with round to oval nuclei and scant cytoplasm, separated by fibrous bands. Scattered mitosis are seen. These cells are positive for cytokeratin, S100 and chromogranin, but negative for CD3, CD20 and CD45. What is most likely the diagnosis?

A. Nasopharyngeal carcinoma

B. NUT midline carcinoma

C. Oncocytic papilloma

D. Olfactory neuroblastoma

E. Small lymphocytic lymphoma

6. Use this case for next two questions. A 65-year-old woman presents with rapidly progressing left side nasal obstruction and double vision for 1 month. She has a history squamous cell carcinoma of lung that was resected 5 years ago. She has been smoking cigarette 1 and half pack per day for 45 years. She does not drink alcohol. Physical examination reveal a mass with lobulated surfaces at left posterolateral nasal wall. Her laboratory tests are within normal range. Radiologic examination reveal a poorly demarcated mass of approximately 5.5 cm in greatest dimension, with extension to left orbital cavity. No abnormalities are seen in both lungs and mediastinum. Biopsy of the mass reveal solid nests of atypical cells with nuclei largely variable in size, shape and staining pattern. No glandular differentiation is seen. Focally there are cells with abundant eosinophilic cytoplasm and recognizable intercellular bridges. What is most likely the diagnosis?

A. Invasive adenocarcinoma

B. Inverted papilloma

C. Malignant lymphoma

D. Metastatic squamous cell carcinoma

E. NUT midline carcinoma

7. A 65-year-old woman presents with rapidly progressing left side nasal obstruction and double vision for 1 month. She has a history squamous cell carcinoma of lung that was resected 5 years ago. She has been smoking cigarette 1 and half pack per day for 45 years. She does not drink alcohol. Physical examination reveal a mass with lobulated surfaces at left posterolateral nasal wall. Her laboratory tests are within normal range. Radiologic examination reveal a poorly demarcated mass of approximately 5.5 cm in greatest dimension, with extension to left orbital cavity. No abnormalities are seen in both lungs and mediastinum. Biopsy of the mass reveal solid nests of atypical cells with nuclei largely variable in size, shape and staining pattern. No glandular differentiation is seen. Focally there are cells with abundant eosinophilic cytoplasm and recognizable intercellular bridges. What diagnostic test would most likely confirm the diagnosis?

A. Histochemistry studies for mucin production

B. Immunohistochemistry studies for androgen receptor expression

C. Immunohistochemistry studies for nuclear expression of NUT

D. Molecular studies for EBV infection.

8. Use this case for next two questions. A 45-year-old man presents with progressing left side nasal obstruction and double vision for 3 month. He is an immigrant from Southeast Asia. He has a history Hodgkin lymphoma that was treated with radiation therapy and chemotherapy 5 years ago. He denies history of cigarette smoking and alcohol drinking, but admit he loves salt-preserve fish. Physical examination is unremarkable. Radiologic examination reveal a poorly demarcated mass of approximately 3.5 cm in greatest dimension at upper central nasapharynx. Biopsy of the mass reveal sheets of markedly atypical cells containing large irregular nuclei, in a background of lymphoplasmcytic infiltrate. No glandular differentiation is seen. Focally there are cells with abundant eosinophilic cytoplasm and recognizable intercellular bridges. Per immunohistochemistry studies, these atypical cells are positive for cytokeratin, but negative for CD45, S-100 and NUT. What is most likely the diagnosis?

A. Diffuse large B cell lymphoma

B. Hodgkin lymphoma

C. Nasopharyngeal carcinoma

D. NUT midline carcinoma

E. Olfactory neuroblastoma

9. A 45-year-old man presents with progressing left side nasal obstruction and double vision for 3 month. He is an immigrant from Southeast Asia. He has a history Hodgkin lymphoma that was treated with radiation therapy and chemotherapy 5 years ago. He denies history of cigarette smoking and alcohol drinking, but admit he loves salt-preserve fish. Physical examination is unremarkable. Radiologic examination reveal a poorly demarcated mass of approximately 3.5 cm in greatest dimension at upper central nasapharynx. Biopsy of the mass reveal sheets of atypical cells containing large irregular nuclei, in a background of lymphoplasmcytic infiltrate. No glandular differentiation is seen. Focally there are cells with abundant eosinophilic cytoplasm and recognizable intercellular bridges. Per immunohistochemistry studies, these atypical cells are positive for cytokeratin, but negative for CD45, S-100 and NUT. What additional marker is most likely positive for these cells?

A. CD20

B. EBV encoded RNA

C. Human Herpes virus 8

D. S-100

E. Synatpophysin

10. Use this case for next two questions. A 53-year-old woman presents with progressing hoarseness for a year. She has a history of follicular carcinoma of thyroid that was treated with total thyroidectomy 15 years ago, and is now on thyroid replacement. She is a science teacher at a local middle school. She smokes cigarette half pack a day for 10 years. She occasionally drinks red wine, but never took more than half glass. Physical examination reveal no significant findings. Laryngoscopy exam reveals a 0.3 cm growth at her left true vocal cord. This lesion has a smooth surface. The lesion is removed and microscopically it has a round fibrous core covered by squamous epithelium. No significant atypia is noted. No koilocytes are seen. In the fibrous core there are scattered lymphocytes with small round nuclei. What is the most likely diagnosis?

A. Recurrent thyroid follicular carcinoma

B. Singer’s nodule

C. Small lymphocytic lymphoma

D. Squamous cell carcinoma

E. Squamous papilloma

11. A 53-year-old woman presents with progressing hoarseness for a year. She has a history of follicular carcinoma of thyroid that was treated with total thyroidectomy 15 years ago, and is now on thyroid replacement. She is a science teacher at a local middle school. She smokes cigarette half pack a day for 10 years. She occasionally drinks red wine, but never took more than half glass. Physical examination reveal no significant findings. Laryngoscopy exam reveals a 0.3 cm growth at her left true vocal cord. This lesion has a smooth surface. The lesion is removed and microscopically it has a round fibrous core covered by squamous epithelium. No significant atypia is noted. No koilocytes are seen. In the fibrous core there are scattered lymphocytes with small round nuclei. What is the most likely associated with these changes?

A. Alcohol usage

B. EBV infection

C. Human papilloma virus infection

D. Recurrent thyroid carcinoma and vocal cord paralysis

E. Voice over usage

12. Use this case for next two questions. A 62-year-old man presents with hoarseness and shortness of breath for 4 months. He has a history of squamous cell carcinoma of lung 5 years ago and was treated with surgery and chemotherapy. Until 5 years ago when he was diagnosed with the lung cancer, he had been smoking cigarette 1 pack a day for 40 years and drinking Scotch whiskey 2 glasses a day for 35 years. He stopped smoking and reduced alcohol drinking to average 1 glass a week since then. Physical examination was unremarkable except inspiratory wheezing. Laryngoscopy examination reveal a 1.2 cm lesion with finger like projections. There is no evidence of ulceration. Microscopic examination of this lesion reveals finger appearing projects with fibrous cores with a few dilated capillaries, and covered by multiple layers of squamous cells. These squamous cells appear to maintain normal polarity but have slightly enlarged hyperchromic nuclei and a clear areas of cytoplasm surround nuclei. The borders of epithelium and the fibrovascular core are smooth. There is no evidence of invasion. What is the most likely diagnosis?

A. Angiosarcoma

B. Hemangioma

C. Singer’s nodule

D. Squamous cell carcinoma

E. Squamous papilloma

13. A 62-year-old man presents with hoarseness and shortness of breath for 4 months. He has a history of squamous cell carcinoma of lung 5 years ago and was treated with surgery and chemotherapy. Until 5 years ago when he was diagnosed with the lung cancer, he had been smoking cigarette 1 pack a day for 40 years and drinking Scotch whiskey 2 glasses a day for 35 years. He stopped smoking and reduced alcohol drinking to average 1 glass a week since then. Physical examination was unremarkable except inspiratory wheezing. Laryngoscopy examination reveal a 1.2 cm lesion with finger like projections. There is no evidence of ulceration. Microscopic examination of this lesion reveals finger like projects with fibrous cores with a few dilated capillaries, and covered by multiple layers of squamous cells. These squamous cells appear to maintain normal polarity but have slightly enlarged hyperchromic nuclei and a clear areas of cytoplasm surround nuclei. The borders of epithelium and the fibrovascular core are smooth. There is no evidence of invasion. What is the most likely causing these changes?

A. Alcohol usage

B. Cigarette smoking

C. EBV infection

D. Human papilloma virus infection

E. Voice over usage

14. Use this case for next two questions. A 67-year-old man presents with progressive hoarseness, loss of appetite and a 20 lb weight loss in the last 6 months. He has a history of nasal allergic polyps. He is a singer for 45 years before retired 5 years ago. Since then he has been active in a local choir, and teach vocal lessons. He has been smoking cigarette half pack a day for 45 years, and drinks wine 2 glasses a day for 30 years. Physical examination reveal a few firm lymph nodes at his left neck. Laryngoscopic examination reveals a 2.5 cm slightly raised growth with ulceration covering his left pyriform fossa, with extension to left vocal cord and epiglottis. This lesion is biopsied and microscopic examination reveals irregularly shaped nests of atypical cells with abundant pink cytoplasm. These cells have nuclei that are markedly varied in size, shape and staining. Nucleoli are seen. Keratin pearls and intercellular bridges are seen. What is the most likely diagnosis?

A. Allergic polyp

B. Singer’s nodule

C. Squamous cell carcinoma

D. Squamous papilloma

15. A 67-year-old man presents with progressive hoarseness, loss of appetite and a 20 lb weight loss in the last 6 months. He has a history of nasal allergic polyps. He is a singer for 45 years before retired 5 years ago. Since then he has been active in a local choir, and teach vocal lessons. He has been smoking cigarette 1 pack a day for 45 years, and drinks wine 2 glasses a day for 30 years. Physical examination reveal a few firm lymph nodes at his left neck. Laryngoscopic examination reveals a 2.5 cm slightly raised growth with ulceration covering his left pyriform fossa, with extension to left vocal cord and epiglottis. This lesion is biopsied and microscopic examination reveals irregularly shaped nests of atypical cells with abundant pink cytoplasm. These cells have nuclei that are markedly varied in size, shape and staining. Nucleoli are seen. Keratin pearls and intercellular bridges are seen. What is the most likely associated with this lesion?

A. Allergic reaction

B. Alcohol usage and cigarette smoking

C. EBV infection

D. NUT abnormality

E. Voice over usage

16. A 29-year-old man presents with intermittent left neck swelling for 3 years. She denies other symptoms. Her past medical history is unremarkable. Physical examination reveal a 5 cm non-tender mass of the upper-left neck. MRI examination reveal a cystic mass beneath left sternocleidomastoid muscle. The mass is resected completely. Pathological examination reveals a cystic lesion with stratified squamous epithelial lining, and scattered infiltrate of lymphocytes and plasma cells. No cytological atypia is seen. What is the most likely diagnosis?

A. Branchial cleft cyst

B. Malignant lymphomaE

C. Sebaceous cyst

D. Squamous cell carcinoma

E. Thyroglossal duct cyst

17. A 34-year-old woman presents with painless swelling at central front neck for 7 months. The swelling is slowly enlarging. She denies weight loss, night sweating and difficulties in swallowing and breathing. Her past medical history is unremarkable. Physical examination reveals a 4x2 soft mobile mass at the midline of upper anterior neck. Laboratory tests are all within normal range. Sonographic examination reveal a single midline cystic mass anterior to the thyroid cartilage. Biopsy reveals fibrous cyst covered respiratory type epithelium. A few lymphocytes are seen in the stroma. What is the most likely diagnosis?

A. Branchial cleft cyst

B. Non specific chronic inflammation

C. Sebaceous cyst

D. Squamous cell carcinoma

E. Thyroglossal duct cyst

Answers

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