Practice questions B, intestinal tumors

Practice questions B, intestinal tumors
© Jun Wang, MD, PhD

1. Use this case and image for the next four questions. A 15-year-old boy presents with fatigue vague abdominal pain for a year. He does not have diarrhea or constipation. He has multiple family members in the paternal side with early onset colon cancers. Physical exam is unremarkable except pale skin. No lymphadenopathy is noted. Laboratory tests reveal a hemoglobin of 8.8 g/dl (normal 12.7-17.7 g/dl) and a positive fecal occult blood test. Image studies are unremarkable. Colonoscopy exam reveals numerous small pedunculated growths involving entire colon. Image of biopsy of one of these growths are shown. What is most likely the diagnosis for the biopsy?
(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Hyperplastic polyp
B. Intramucosal adenocarcinoma
C. Sessile serrated adenoma
D. Tubular adenoma
E. Villous adenoma

2. A 15-year-old boy presents with fatigue vague abdominal pain for a year. He does not have diarrhea or constipation. He has multiple family members in the paternal side with early onset colon cancers. Physical exam is unremarkable except pale skin. No lymphadenopathy is noted. Laboratory tests reveal a hemoglobin of 8.8 g/dl (normal 12.7-17.7 g/dl) and a positive fecal occult blood test. Image studies are unremarkable. Colonoscopy exam reveals numerous small pedunculated growths involving entire colon. Image of biopsy of one of these growths are shown. What is most likely the diagnosis for the patient?

(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])

A. Familial adenomatous polyposis
B. Gardner syndrome
C. Juvenile polyposis
D. Lynch syndrome
E. Peutz-Jeghers syndrome

3. A 15-year-old boy presents with fatigue vague abdominal pain for a year. He does not have diarrhea or constipation. He has multiple family members in the paternal side with early onset colon cancers. Physical exam is unremarkable except pale skin. No lymphadenopathy is noted. Laboratory tests reveal a hemoglobin of 8.8 g/dl (normal 12.7-17.7 g/dl) and a positive fecal occult blood test. Image studies are unremarkable. Colonoscopy exam reveals numerous small pedunculated growths involving entire colon. Image of biopsy of one of these growths are shown. Mutation of what gene is likely to be associated with his condition?

(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. APC
B. C-kit
C. MSI
D. SMAD4
E. STK11

4. A 15-year-old boy presents with fatigue vague abdominal pain for a year. He does not have diarrhea or constipation. He has multiple family members in the paternal side with early onset colon cancers. Physical exam is unremarkable except pale skin. No lymphadenopathy is noted. Laboratory tests reveal a hemoglobin of 8.8 g/dl (normal 12.7-17.7 g/dl) and a positive fecal occult blood test. Image studies are unremarkable. Colonoscopy exam reveals numerous small pedunculated growths involving entire colon. Image of biopsy of one of these growths are shown. What cellular function abnormality is most likely associated with these findings?

(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])

A. Beta-catenin degradation
B. DNA mismatch repair
C. P53 degradation
D. Retinoblastoma 1 inactivation
E. Telomerase activation


5. Use this case and image for the next four questions. A 37-year-old woman presents with dull abdominal pain, abdominal distention, nausea, vomiting and bloody stools for 3 months. She has a history of mandible osteoma 12 years ago that was treated with surgery. She has a pack-year 30 history of cigarette smoking. Her family history is significant for early onset colon cancer. The physical examination reveals abdominal distention and a centrally located intra-abdominal mass. Laboratory tests reveal a hemoglobin of 8.3 g/dl (normal 12-16 g/dl). Her white cells and platelets are within normal range. Peripheral blood smear reveals no significant morphological abnormality. Fecal occult blood test is positive. Abdominal ultrasound revealed a 12 cm mesentery mass. Biopsy of the mass reveals benign appearing spindle cells. Per immunohistochemistry studies, these spindle cells are positive for vimentin, but negative for desmin, S100 and CD34. Proliferative index per ki67 is less than 1%. What test should be performed next?
A. Bone marrow biopsy
B. Chest CT
C. Colonoscopy
D. Flow cytometry for peripheral blood
E. Serum iron analysis

6. A 37-year-old woman presents with dull abdominal pain, abdominal distention, nausea, vomiting and bloody stools for 3 months. She has a history of mandible osteoma 12 years ago that was treated with surgery. She has a pack-year 30 history of cigarette smoking. Her family history is significant for early onset colon cancer. The physical examination reveals abdominal distention and a centrally located intra-abdominal mass. Laboratory tests reveal a hemoglobin of 8.3 g/dl (normal 12-16 g/dl). Her white cells and platelets are within normal range. Peripheral blood smear reveals no significant morphological abnormality. Fecal occult blood test is positive. Abdominal ultrasound revealed a 12 cm mesentery mass. Biopsy of the mass reveals benign appearing spindle cells. Per immunohistochemistry studies, these spindle cells are positive for vimentin, but negative for desmin, S100 and CD34. Proliferative index per ki67 is less than 1%. Colonoscopic exam reveals numerous polypoid growth in her transvers and descending colon. An image of her biopsy is shown. What is the diagnosis for this polyp?
(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Hyperplastic polyp
B. Intramucosal adenocarcinoma
C. Peutz-Jegher polyp
D. Tubular adenoma
E. Villous adenoma

7. A 37-year-old woman presents with dull abdominal pain, abdominal distention, nausea, vomiting and bloody stools for 3 months. She has a history of mandible osteoma 12 years ago that was treated with surgery. She has a pack-year 30 history of cigarette smoking. Her family history is significant for early onset colon cancer. The physical examination reveals abdominal distention and a centrally located intra-abdominal mass. Laboratory tests reveal a hemoglobin of 8.3 g/dl (normal 12-16 g/dl). Her white cells and platelets are within normal range. Peripheral blood smear reveals no significant morphological abnormality. Fecal occult blood test is positive. Abdominal ultrasound revealed a 12 cm mesentery mass. Biopsy of the mass reveals benign appearing spindle cells. Per immunohistochemistry studies, these spindle cells are positive for vimentin, but negative for desmin, S100 and CD34. Proliferative index per ki67 is less than 1%. Colonoscopic exam reveals numerous polypoid growth in her transvers and descending colon. An image of her biopsy is shown. What is her condition?
A. Gardner syndrome
B. Inflammatory bowel disease
C. Juvenile polyposis
D. Lynch syndrome
E. Peutz-Jeghers syndrome

8. A 37-year-old woman presents with dull abdominal pain, abdominal distention, nausea, vomiting and bloody stools for 3 months. She has a history of mandible osteoma 12 years ago that was treated with surgery. She has a pack-year 30 history of cigarette smoking. Her family history is significant for early onset colon cancer. The physical examination reveals abdominal distention and a centrally located intra-abdominal mass. Laboratory tests reveal a hemoglobin of 8.3 g/dl (normal 12-16 g/dl). Her white cells and platelets are within normal range. Peripheral blood smear reveals no significant morphological abnormality. Fecal occult blood test is positive. Abdominal ultrasound revealed a 12 cm mesentery mass. Biopsy of the mass reveals benign appearing spindle cells. Per immunohistochemistry studies, these spindle cells are positive for vimentin, but negative for desmin, S100 and CD34. Proliferative index per ki67 is less than 1%. Colonoscopic exam reveals numerous polypoid growth in her transvers and descending colon. An image of her biopsy is shown. Mutation of what gene is most likely associated with these findings?
A. APC
B. C-kit
C. MSI
D. SMAD4
E. STK11


9. Use this case and image for the next four questions. A 45-year-old woman presents with increased frequency of bowel movement for last 3 months. She was diagnosed with FIGO I endometrial endometrioid adenocarcinoma 4 years ago that was treated with total hysterectomy. Her past medical history is otherwise unremarkable. Her family history is significant for colon and endometrial cancers. Physical examination is unremarkable except rectal digital exam finding of a firm mass at the posterior wall. Her routine laboratory tests are within normal range. Radiologic examination reveals no evidence of lymphadenopathy. No other abnormalities are noted. Colonoscopy exam reveals an ulcerated mass approximately 3 cm above anal verge. The colon is otherwise unremarkable. An image of the biopsy is shown. No squamous differentiation is seen. What is the diagnosis?
(Image credit: Kwz~commonswiki)
A. Metastatic endometrioid adenocarcinoma
B. Peutz-Jegher polyp
C. Primary rectal adenocarcinoma
D. Tubular adenoma
E. Villous adenoma

10. A 45-year-old woman presents with increased frequency of bowel movement for last 3 months. She was diagnosed with FIGO I endometrial endometrioid adenocarcinoma 4 years ago that was treated with total hysterectomy. Her past medical history is otherwise unremarkable. Her family history is significant for colon and endometrial cancers. Physical examination is unremarkable except rectal digital exam finding of a firm mass at the posterior wall. Her routine laboratory tests are within normal range. Radiologic examination reveals no evidence of lymphadenopathy. No other abnormalities are noted. Colonoscopy exam reveals an ulcerated mass approximately 3 cm above anal verge. The colon is otherwise unremarkable. An image of the biopsy is shown. No squamous differentiation is seen. Mutation of what gene is most likely associated with her presentations?
(Image credit: Kwz~commonswiki)
A. APC
B. BRCA
C. MSIs
D. SMAD4
E. STK11

11. A 45-year-old woman presents with increased frequency of bowel movement for last 3 months. She was diagnosed with FIGO I endometrial endometrioid adenocarcinoma 4 years ago that was treated with total hysterectomy. Her past medical history is otherwise unremarkable. Her family history is significant for colon and endometrial cancers. Physical examination is unremarkable except rectal digital exam finding of a firm mass at the posterior wall. Her routine laboratory tests are within normal range. Radiologic examination reveals no evidence of lymphadenopathy. No other abnormalities are noted. Colonoscopy exam reveals an ulcerated mass approximately 3 cm above anal verge. The colon is otherwise unremarkable. An image of the biopsy is shown. No squamous differentiation is seen. Per immunohistochemistry studies, these glandular cells are positive for MLH1, PMS2 but negative for MSH2 and MSH6. What is the diagnosis for her condition?
(Image credit: Kwz~commonswiki)
A. Cowden syndrome
B. Gardner syndrome
C. Juvenile polyposis
D. Lynch syndrome
E. Peutz-Jeghers syndrome

12. A 45-year-old woman presents with increased frequency of bowel movement for last 3 months. She was diagnosed with FIGO I endometrial endometrioid adenocarcinoma 4 years ago that was treated with total hysterectomy. Her past medical history is otherwise unremarkable. Her family history is significant for colon and endometrial cancers. Physical examination is unremarkable except rectal digital exam finding of a firm mass at the posterior wall. Her routine laboratory tests are within normal range. Radiologic examination reveals no evidence of lymphadenopathy. No other abnormalities are noted. Colonoscopy exam reveals an ulcerated mass approximately 3 cm above anal verge. The colon is otherwise unremarkable. An image of the biopsy is shown. No squamous differentiation is seen. Per immunohistochemistry studies, these glandular cells are positive for MLH1, PMS2 but negative for MSH2 and MSH6. What cellular function abnormality is most likely associated with these findings?
(Image credit: Kwz~commonswiki)
A. Beta-catenin nuclear translocation
B. DNA mismatch repair
C. P53 degradation
D. Retinoblastoma 1 inactivation
E. Telomerase activation


13. Use this image for this question. A 71-year-old man presents with fatigue and right lower abdomen discomfort for 6 months. He denies other symptoms. His medical history include squamous cell carcinoma of lung, chronic cholecystitis, hypertension and type 2 diabetes. His family history is unremarkable. He has a 50 pack-year history of cigarette smoking. He drinks 2 cans of beer each day since age 45. Physical examination is unremarkable. Laboratory tests reveal a hemoglobin of 11 g/dl (normal 13-18 g/dl). His white cell and platelets are within normal ranges. Peripheral blood smear reveal no significant morphological abnormality. Fecal occult blood test is positive. Colonoscopy exam reveals a 5.5 cm ulcerated mass at his cecum. Image of the biopsy is shown. What is the diagnosis?
(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Juvenile polyp
B. Metastatic squamous cell carcinoma
C. Mucinous adenocarcinoma
D. Tubular adenoma
E. Villous adenoma

14. Use this case and this image for the next two questions. A 65-year-old man presents with progressive right lower abdomen pain. She has a history of adenocarcinoma of left lung at age of 56 and was treated with surgery and chemotherapy. Her past medical history is otherwise unremarkable. Physical examination reveals no significant abnormalities. CBC reveals a hemoglobin of 7.5 g/dl (normal 12-16 g/dl), MCV of 75 fl (normal 85-95 fl) and red cell distribution width of 18% (normal 13-15%). Additional laboratory tests results including iron of 23 mcg/dl (normal 50-150 mcg/dl) and UIBC of 410 mcg/dl (normal 200-305 mcg/dl). Fecal occult blood test is positive. What is the next step of management?
A. Bone marrow biopsy
B. Colonoscopy
C. Folate supplementation
D. Iron supplementation
E. Peripheral blood flow cytometry

15. A 65-year-old man presents with progressive right lower abdomen pain. She has a history of adenocarcinoma of left lung at age of 56 and was treated with surgery and chemotherapy. Her past medical history is otherwise unremarkable. Physical examination reveals no significant abnormalities. CBC reveals a hemoglobin of 7.5 g/dl (normal 12-16 g/dl), MCV of 75 fl (normal 85-95 fl) and red cell distribution width of 18% (normal 13-15%). Additional laboratory tests results including iron of 23 mcg/dl (normal 50-150 mcg/dl) and UIBC of 410 mcg/dl (normal 200-305 mcg/dl). Fecal occult blood test is positive. Colonoscopy examination reveals a 2.4 cm mass at his ascending colon. An image of the biopsy is shown. Per immunohistochemistry studies, these cells are negative for TTF1. What is the diagnosis?
(Image credit: Patho [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Adenocarcinoma, NOS
B. Carcinoid
C. Hyperplastic polyp
D. Metastatic pulmonary adenocarcinoma
E. Signet ring cell carcinoma

16. Use this image for this question. A 35-year-old man presents with worsening epigastric pain and a 20 pound weight loss in the last 6 months. He has a history of reflux gastritis for 5 years and ulcerative colitis for 13 years. His medical history is otherwise unremarkable. Physical examination and routine laboratory tests reveal no significant abnormalities. Colonoscopy exam reveal diffuse erythematous changes with many polypoid growths involving transverse and sigmoid colon. A 2.5 cm transverse colon polyp has focal surface ulceration. An image of a biopsy of this polyp is shown. What is the diagnosis?
(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Adenocarcinoma, NOS
B. Hyperplastic polyp
C. Inflammatory polyp
D. Juvenile polyp
E. Mucinous adenocarcinoma


17. Use this case and this image for the next two questions. A 49-year-old homosexual man presents with anal pain for 3 months. He denies other symptoms. He is HIV positive since age 30, and has history of syphilic chancre at age 23, that was treated with penicillin, and multiple episodes of genital herpes and condyloma. Rectal digital exam reveals a firm mass 2 cm above verge. His laboratory tests reveals a CD4+ T cell count of 350/mcl (normal 500-1500/mcl). No other abnormalities are noted. An image of the biopsy is shown. Per immunohistochemistry studies, these cells are positive for cytokeratin, and negative for CD20, CD45, S100 and chromogranin. What is the diagnosis?
(Image credit: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Condyloma
B. Melanoma
C. Small cell carcinoma
D. Small lymphocytic lymphoma
E. Squamous cell carcinoma

18. A 49-year-old homosexual man presents with anal pain for 3 months. He denies other symptoms. He is HIV positive since age 30, and has history of syphilic chancre at age 23, that was treated with penicillin, and multiple episodes of genital herpes and condyloma. Rectal digital exam reveals a firm mass 2 cm above verge. His laboratory tests reveals a CD4+ T cell count of 350/mcl (normal 500-1500/mcl). No other abnormalities are noted. An image of the biopsy is shown. Per immunohistochemistry studies, these cells are positive for cytokeratin, and negative for CD20, CD45, S100 and chromogranin. What is most likely associated with this lesion?

(Image credit: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. EB virus
B. Human herpes virus 2
C. Human immunodeficiency virus
D. Human papilloma virus
E. Treponema pallidum


19. Use this image for this question. A 29-year-old woman presents with recurrent right abdomen dull pain for 6 months. She has a history of dysmenorrhea since age 21. Her past medical history is otherwise unremarkable. Physical examination reveals tenderness at right lower abdomen without rebound tenderness or guarding. No other abnormalities are noted. Laboratory test results are within normal range. Abdominal CT reveals enlarged appendix. Appendectomy was performed and a 0.5 cm pale area is noted at the tip. Image of the microscopic exam is shown. Per immunohistochemistry studies, these cells are positive for cytokeratin and chromogranin. What is the diagnosis?
(Image credit: Sarahkayb [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)])
A. Adenocarcinoma
B. Carcinoid
C. Chronic appendicitis
D. Endometriosis
E. Small cell carcinoma

20. A 45-year-old woman presents with vague lower abdominal pain for 6 months. Her past medical history is unremarkable. Physical examination reveals tenderness at left and right lower abdominal without rebound tenderness or guarding. Her laboratory test results are within normal ranges. Image studies reveals a dilated appendix, and multiple small masses up to 1.5 cm on the serosa side of her uterus and rectum. Laparotomy was performed. Gelatinous material are seen attached to appendix, and uterus, rectum and parietal peritoneum. Microscopic examination of the appendix reveal a cystic dilation lined by columnar cells with abundant pale cytoplasm. Focally there are signs of perforation. No cytological atypia are seen. What is most likely the diagnosis?
A. Carcinoid
B. Mucinous adenocarcinoma
C. Ovarian borderline mucinous neoplasm
D. Peritoneal carcinomatosis
E. Pseudomyxoma peritonei


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