Practice questions A, intestinal tumors

Practice questions A, intestinal tumors 

© Jun Wang, MD, PhD

1. Use this case and this image for the next three questions. A 68-year-old woman presents with fatigue for 3 months. She has type 2 diabetes, obesity and Graves disease. She smokes cigarette 1 pack a day for 15 years, and is a social drinker. Her family history is significant for multiple female relatives with endometrial and breast cancers. Physical examination reveals no significant findings except slightly pale conjunctiva and a BMI of 31 (normal 18.5-24.9). Laboratory test reveals a hemoglobin of 8.5 g/dl (normal 12 – 15 g/dl), red cell distribution width (RDW) of 16% (normal 13-15), and serum ferritin of 16 mcg/l (normal 18-160 mcg/l). Her white cells, platelets, PT and aPTT are within normal range. Peripheral blood smears reveal no significant morphological abnormalities nor immature cells. Image studies are unremarkable. What is a proper test for diagnosis?

A. Colonoscopy

B. Genetic counseling

C. Hemoglobin electrophoresis

D. Lymphocytes phenotyping

E. Platelet function tests

2. A 68-year-old woman presents with fatigue for 3 months. She has type 2 diabetes, obesity and Graves disease. She smokes cigarette 1 pack a day for 15 years, and is a social drinker. Her family history is significant for multiple female relatives with endometrial and breast cancers. Physical examination reveals no significant findings except slightly pale conjunctiva and a BMI of 31 (normal 18.5-24.9). Laboratory test reveals a hemoglobin of 8.5 g/dl (normal 12 – 15 g/dl), red cell distribution width (RDW) of 16% (normal 13-15), and serum ferritin of 16 mcg/l (normal 18-160 mcg/l). Her white cells, platelets, PT and aPTT are within normal range. Peripheral blood smears reveal no significant morphological abnormalities nor immature cells. Image studies are unremarkable.

Colonoscopy examination reveal a 1.5 cm pedunculated polyp with focal ulceration at her splenic flexure. Polypectomy was performed and the microscopic findings are shown. What is the diagnosis?

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

A. Adenocarcinoma

B. Hyperplastic polyp

C. Juvenile polyp

D. Sessile serrated adenoma

E. Tubular adenoma

3. A 68-year-old woman presents with fatigue for 3 months. She has type 2 diabetes, obesity and Graves disease. She smokes cigarette 1 pack a day for 15 years, and is a social drinker. Her family history is significant for multiple female relatives with endometrial and breast cancers. Physical examination reveals no significant findings except slightly pale conjunctiva and a BMI of 31 (normal 18.5-24.9). Laboratory test reveals a hemoglobin of 8.5 g/dl (normal 12 – 15 g/dl), red cell distribution width (RDW) of 16% (normal 13-15), and serum ferritin of 16 mcg/l (normal 18-160 mcg/l). Her white cells, platelets, PT and aPTT are within normal range. Peripheral blood smears reveal no significant morphological abnormalities nor immature cells. Image studies are unremarkable. Colonoscopy examination reveal a 1.5 cm pedunculated polyp with focal ulceration at her splenic flexure. Polypectomy was performed and the microscopic findings are shown. What is most likely the cause of these findings?

 

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

A. Activating mutation of beta catenin

B. Chronic inflammation

C. Delayed shedding of surface epithelial cells

D. Hypermethylation of CpG island

E. Microsatellite instability

4. Use this image for this questions. A 39-year-old woman presents with worsening fatigue for two months. She has a history of ulcerative colitis for 8 years. Physical examination is unremarkable. Her laboratory tests reveal a hemoglobin of 7.5 g/dl (normal 12-15 g/dl) and mcv of 72 fl (normal 80-96 fl). Other routine tests are within normal range. Colonoscopy examination reveals diffuse mild to moderate inflammatory changes and a few polypoid growths up to 1.2 cm in greatest dimension. Image of the biopsy is shown. No significant atypia is noted. What is the diagnosis concerning the polyp biopsied?

 

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

A. Hyperplastic polyp

B. Inflammatory polyp

C. Intramucosal adenocarcinoma

D. Sessile serrated adenoma

E. Tubular adenoma

5. Use this case and this image for the next two questions. A 2-year-old boy presents with melena for 3 months. His past medical history is unremarkable. Physical examination reveals pale conjunctiva and both weight and heights at 15^th percentile. No skin or mucosal pigmentation is noted. Laboratory tests reveals a hemoglobin at 5.5 g/dl (normal 10.5-14.5 g/dl). Blood smear reveals no morphological abnormalities. Upper endoscopic examination reveals a few ulcerated bleeding gastric polyps. Colonoscopy examination reveals multiple pedunculated polyps in his colon. Microscopically, the colon polyps have same morphology. Image of the gastric polyp is shown. What is most likely the diagnosis?

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

A. Hyperplastic polyps

B. Inflammatory polyps

C. Juvenile polyposis

D. Peutz-Jeghers syndrome

E. Sessile serrated adenoma

6. A 2-year-old boy presents with melena for 3 months. His past medical history is unremarkable. Physical examination reveals pale conjunctiva and both weight and heights at 15^th percentile. No skin or mucosal pigmentation is noted. Laboratory tests reveals a hemoglobin at 5.5 g/dl (normal 10.5-14.5 g/dl). Blood smear reveals no morphological abnormalities. Upper endoscopic examination reveals a few ulcerated bleeding gastric polyps. Colonoscopy examination reveals multiple pedunculated polyps in his colon. Microscopically, the colon polyps have same morphology. Image of the gastric polyp is shown. Mutation of what gene is most likely associated with these findings?

A. APC

B. Beta-catenin

C. MYH

D. SMAD4

E. STK11

7. Use this case and this image for the next two questions. A 38-year-old man presents with intermittent melena for 2 months. He does not have diarrhea, constipation or abdominal pain. His past medical history is unremarkable. He has a few family members with lung, colon and breast cancers. He does not smoke cigarette nor drink alcohol. Physical examination reveals a few irregular brown macules at his lips, conjunctiva, chest and back. Laboratory tests are unremarkable except positive fecal occult blood test. Image studies reveals multiple masses in his colon. Colonoscopy exam reveals masses up to 2.5 cm in greatest dimension in his ascending and sigmoid colon. Some of theses masses are ulcerated. An image of the biopsy is shown. No cytological atypia is noted. What is the diagnosis?

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

A. Hyperplastic polyps

B. Inflammatory polyps

C. Juvenile polyposis

D. Peutz-Jeghers syndrome

E. Sessile serrated adenoma

8. A 38-year-old man presents with intermittent melena for 2 months. He does not have diarrhea, constipation or abdominal pain. His past medical history is unremarkable. He has a few family members with lung, colon and breast cancers. He does not smoke cigarette nor drink alcohol. Physical examination reveals a few irregular brown macules at his lips, conjunctiva, chest and back. Laboratory tests are unremarkable except positive fecal occult blood test. Image studies reveals multiple masses in his colon. Colonoscopy exam reveals masses up to 2.5 cm in greatest dimension in his ascending and sigmoid colon. Some of theses masses are ulcerated. An image of the biopsy is shown. No cytological atypia is noted. Mutation of what gene is most likely associated with these findings?

 

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

A. APC

B. Beta-catenin

C. MYH

D. SMAD4

E. STK11

9. Use this image for this question. A 65-year-old woman presents for screening colonoscopy exam. She denies symptoms of diarrhea, constipation, abdominal pain or weight loss. She has adenocarcinoma of lung diagnosed two years ago that was treated with surgery and chemotherapy. She also has type 2 diabetes, hypertension and hypothyroidism. She denies cigarette or alcohol usage. Physical examination is unremarkable. Colonoscopy examination reveals a single pedunculated polyp at her cecum. An image is shown. No significant cytological atypia is noted. What is the diagnosis?

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

A. Hyperplastic polyp

B. Sessile serrated adenoma

C. Tubular adenoma

D. Tubulovillous adenoma

E. Villous adenoma

10. Use this image for this question. A 59-year-old man presents with fatigue for 3 months. He does not have other symptoms. His past medical history is unremarkable. Physical examination reveals slightly pale skin. Laboratory tests reveal a hemoglobin of 11.2 g/dl (normal 13-18 g/dl). Fecal occult blood test is positive. Image studies reveal a 2 cm mass at his transverse colon. Colonoscopy exam reveals a polypoid growth with wide base and a cauliflower like surface. No ulcer is noted. Image of the biopsy is shown. No significant cytological atypia is noted. What is the diagnosis?

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

A. Hyperplastic polyp

B. Sessile serrated adenoma

C. Tubular adenoma

D. Tubulovillous adenoma

E. Villous adenoma

11. Use this image for this question.  A 66-year-old woman presents with fatigue for 3 months. She does not have diarrhea, constipation, or weight loss. Her past medical history including FIGO I endometrial adenocarcinoma. Physical examination reveals slightly pale skin. Laboratory tests reveal a hemoglobin of 9.6 g/dl (normal 13-18 g/dl). Fecal occult blood test is positive. Colonoscopy exam reveals a polypoid growth with wide base and a focally ulcerated cauliflower like surface. Image of the biopsy is shown. No significant cytological atypia is noted. What is the diagnosis?

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

A. Metastatic endometrial adenocarcinoma

B. Sessile serrated adenoma

C. Tubular adenoma

D. Tubulovillous adenoma

E. Villous adenoma

12. Use this case and this image for the next two questions. A 77-year-old man presents with fatigue and vague left lower abdominal discomfort. He has a history of hypertension, type 2 diabetes and prostate adenocarcinoma. His family history is significant for multiple members with colon and lung cancers. Laboratory tests results, including PSA, are within normal range. Colonoscopy exam reveals a 2.5 cm flat growth with a cauliflower appearing surface at his sigmoid colon. No ulcer nor hemorrhage is noted. An 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. Metastatic prostate adenocarcinoma

B. Sessile serrated adenoma

C. Tubular adenoma

D. Tubulovillous adenoma

E. Villous adenoma

13. A 77-year-old man presents with fatigue and vague left lower abdominal discomfort. He has a history of hypertension, type 2 diabetes and prostate adenocarcinoma. His family history is significant for multiple members with colon and lung cancers. Laboratory tests results, including PSA, are within normal range. Colonoscopy exam reveals a 2.5 cm flat growth with a cauliflower appearing surface at his sigmoid colon. No ulcer nor hemorrhage is noted. An image of the biopsy is shown. Mutation of what gene is likely associated with these changes?

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

A. Androgen receptor

B. Beta-catenin

C. MSI

D. SMAD4

E. STK11

14. Use this case and this image for the next two questions. A 66-year-old woman presents with fatigue for 3 months. She does not have diarrhea, constipation, or weight loss. Her past medical history and physical examination are unremarkable. Laboratory tests reveal a hemoglobin of 8.5 g/dl (normal 12-15 g/dl). Fecal occult blood test is positive. No other abnormalities are noted. Colonoscopy exam reveals a 1.5 cm pedunculated growth with smooth surface at her sigmoid colon. The growth is removed. Majority of the growth is composed of tubular glands lined by cells with basally located crowded elongated hyperchromic nuclei. At a small focus there are glands as shown. These glands are only seen in the mucosa and does not involve the margin. What is the diagnosis?

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

B. Mucinous adenocarcinoma

C. Sessile serrated adenoma

D. Tubular adenoma

E. Villous adenoma

15. A 66-year-old woman presents with fatigue for 3 months. She does not have diarrhea, constipation, or weight loss. Her past medical history and physical examination are unremarkable. Laboratory tests reveal a hemoglobin of 8.5 g/dl (normal 12-15 g/dl). Fecal occult blood test is positive. No other abnormalities are noted. Colonoscopy exam reveals a 1.5 cm pedunculated growth with smooth surface at her sigmoid colon. The growth is removed. Majority of the growth is composed of tubular glands lined by cells with basally located crowded elongated hyperchromic nuclei. At a small focus there are glands as shown. These glands are only seen in the mucosa and do not involve the margin. How is the patient need to be treated?

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

A. Chemotherapy

B. Colectomy

C. Mucosal resection with lymph node dissection

D. No additional treatment

E. Radiation therapy

 

 

16. Use this case and this image for the next three questions. A 39-year-old man presents with fatigue for 6 months. He has a history of type 1 diabetes, obesity and major depression. He denies other symptoms, including night sweating, nausea and weight loss. His family history is remarkable for a few family members in the paternal side who were diagnosed with colon or rectal cancer from age 40 to 55. He has a 10 pack year history of cigarette smoking, but denies usage of alcohol or illicit drugs. Physical examination reveals no significant findings except a body weight of 280 pounds. His laboratory findings are within normal ranges, except a hemoglobin of 10.8 g/dl (14-18 g/dL) and elevated blood lipid levels including a total cholesterol of 320 mg/dL (125-200 mg/dL). Colonoscopic exam reveals approximately 30 polyps, up to 0.7 cm in greatest dimension, scattered in his ascending and transverse colon. An image of microscopic examination of these polyps are shown. Molecular tests of what genes are most likely to confirm the diagnosis?

(Image Credit: Nephron, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)

A. APC and MUTYH
B. BMPR1A and SMAD4
C. Microsatellite-instability mutations and CpG methylation
D. PTEN and STK11
E. TSC1 and TSC2

17. A 39-year-old man presents with fatigue for 6 months. He has a history of type 1 diabetes, obesity and major depression. He denies other symptoms, including night sweating, nausea and weight loss. His family history is remarkable for a few family members in the paternal side who were diagnosed with colon or rectal cancer from age 40 to 55. He has a 10 pack year history of cigarette smoking, but denies usage of alcohol or illicit drugs. Physical examination reveals no significant findings except a body weight of 280 pounds. His laboratory findings are within normal ranges, except a hemoglobin of 10.8 g/dl (14-18 g/dL) and elevated blood lipid levels including a total cholesterol of 320 mg/dL (125-200 mg/dL). Colonoscopic exam reveals approximately 30 polyps, up to 0.7 cm in greatest dimension, scattered in his ascending and transverse colon. An image of microscopic examination of these polyps are shown. Mutation of what gene is most likely seen in this patient?

(Image Credit: Nephron, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
A. APC
B. BMPR1A
C. MUTYH
D. SMAD4
E. STK11

18. A 39-year-old man presents with fatigue for 6 months. He has a history of type 1 diabetes, obesity and major depression. He denies other symptoms, including night sweating, nausea and weight loss. His family history is remarkable for a few family members in the paternal side who were diagnosed with colon or rectal cancer from age 40 to 55. He has a 10 pack year history of cigarette smoking, but denies usage of alcohol or illicit drugs. Physical examination reveals no significant findings except a body weight of 280 pounds. His laboratory findings are within normal ranges, except a hemoglobin of 10.8 g/dl (14-18 g/dL) and elevated blood lipid levels including a total cholesterol of 320 mg/dL (125-200 mg/dL). Colonoscopic exam reveals approximately 30 polyps, up to 0.7 cm in greatest dimension, scattered in his ascending and transverse colon. An image of microscopic examination of these polyps are shown. What type of polyp this is?


(Image Credit: Nephron, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
A. Hyperplastic polyp
B. Inflammatory polyp
C. Sessile serrated adenoma
D. Tubular adenoma
E. Villous adenoma

Answers

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