Practice questions, skin tumors 2

Practice questions, skin tumors 2
© Jun Wang, MD, PhD

1. Use this case and this image for the next two questions. A 65-year-old male farmer presents with an incidentally found slightly discolored skin lesion on his forehead. He denies other symptoms. He has a history of multiple squamous cell carcinomas and basal cell carcinomas of skin, all treated with local resections. Physical examination reveals a 2.5 cm slightly erythematous area with a rough surface at his left forehead. No other significant abnormalities are noted. An image of the biopsy is shown. What is the diagnosis?

(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Actinic keratosis
B. Basal cell carcinoma
C. Bowen disease
D. Dermatophytosis
E. Melanoma in situ

2. A 65-year-old male farmer presents with an incidentally found slightly discolored skin lesion on his forehead. He denies other symptoms. He has a history of multiple squamous cell carcinomas and basal cell carcinomas of skin, all treated with local resections. Physical examination reveals a 2.5 cm slightly erythematous area with a rough surface at his left forehead. No other significant abnormalities are noted. An image of the biopsy is shown. What disease is likely to develop from this lesion?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Diffuse large B cell lymphoma
B. Invasive melanoma
C. Merkel cell carcinoma
D. Sezary syndrome
E. Squamous cell carcinoma


3. Use this case and this image for the next two questions. A 59-year-old man presents with a slowly growing nodule at his left forearm. He has a history of diabetes. The nodule has a smooth surface with dilated vessels. An image of the biopsy is shown. What is the most important cause of this lesion?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Abnormal keratinocyte turn over
B. Chronic irritation
C. Human papilloma virus
D. Insulin resistance
E. Sun exposure

4. A 59-year-old man presents with a slowly growing nodule at his left forearm. The nodule has a smooth surface with dilated vessels. An image of the biopsy is shown. What is the diagnosis?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Actinic keratosis
B. Basal cell carcinoma
C. Cylindroma
D. Psoriasis
E. Tricholemmoma


5. Use this case and this image for the next three questions. A 61-year-old woman presents with a slowly growing painless skin nodule at her left upper lip. Her past medical history is unremarkable. Physical examination reveals a 3 mm papule with scar appearing smooth surface. No other abnormality is noted. An image of the biopsy is shown. What is likely to be found in this lesion?

(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Distant metastasis
B. Multifocality
C. Perineural invasion
D. Primitive hair follicles
E. Squamous pearls

6. A 61-year-old woman presents with a slowly growing painless skin nodule at her left upper lip. Her past medical history is unremarkable. Physical examination reveals a 3 mm papule with scar appearing smooth surface. No other abnormality is noted. An image of the biopsy is shown. What is the proper treatment?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Chemotherapy
B. Cryotherapy
C. Mohs surgery
D. Topical steroid
E. Wide excision

7. A 61-year-old woman presents with a slowly growing painless skin nodule at her left upper lip. Her past medical history is unremarkable. Physical examination reveals a 3 mm papule with scar appearing smooth surface. No other abnormality is noted. An image of the biopsy is shown. What is the diagnosis?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Actinic keratosis
B. Basal cell carcinoma
C. Cylindroma
D. Syringoma
E. Tricholemmoma


8. Use this case and this image for the next two questions. A 55-year-old woman presents with a waxy skin lesion at her left forearm. Physical examination reveals a 0.5 cm tan rough scaling macule. An image of the biopsy is shown. What is likely to be found in this lesion?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Distant metastasis
B. Multifocality
C. Perineural invasion
D. Primitive hair follicles
E. Squamous pearls

9. A 55-year-old woman presents with a waxy skin lesion at her left forearm. Physical examination reveals a 0.5 cm tan rough scaling macule. An image of the biopsy is shown. What is the diagnosis?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Actinic keratosis
B. Basal cell carcinoma
C. Cylindroma
D. Syringoma
E. Tricholemmoma


10. Use this image this question. A 48-year-old man presents with a 0.8 cm painless nodule at his forehead. Image of the biopsy is shown. Mutation of what gene is likely associated with this lesion?
(Image: Ed Uthman, MD [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)])
A. Beta-catenin
B. BRAF
C. CYLD
D. MSH2
E. PTCH

11. Use this case and this image for the next two questions. A 51-year-old man presents with a rapid growing painless nodule at his forehead. Image of the biopsy is shown. Per immunohistochemistry studies, this lesion is positive for pan cytokeratin, CD56 and negative for CD45, and TTF 1. What additional marker is likely to be positive?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. CD3
B. CD20
C. CK7
D. CK20
E. Desmin

12. A 51-year-old man presents with a rapid growing painless nodule at his forehead. Image of the biopsy is shown. Per immunohistochemistry studies, this lesion is positive for pan cytokeratin, CD56 and negative for CD45, and TTF 1. What is most likely the diagnosis?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Basal cell carcinoma
B. Cylindroma
C. Diffuse large B cell lymphoma
D. Merkel cell carcinoma
E. Poroma


13. Use this image this question. A 71-year-old man presents with a pruritic skin lesion at his right hands. The lesion is slightly raised with a scaly surface up to 1.5 cm in greatest dimension. He has a history of multiple squamous cell carcinoma and melanoma for the last 10 years. An image of the biopsy is shown. These changes are only seen in the epidermis. No atypical cells are noted in the dermis. Per immunohistochemistry studies, no S-100 positive cells are seen beyond the basal layer. What is the diagnosis?
(Image: KGH assumed (based on copyright claims). [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)])
A. Actinic keratosis
B. Basal cell carcinoma
C. Bowen disease
D. Invasive squamous cell carcinoma
E. Melanoma in situ


14. Use this case and this image for the next two questions. A 57-year-old man presents with a ulcerated mass on his left face. He has had multiple basal cell carcinoma and melanoma. He has a 45 pack-year history of cigarette smoking and has been working in a polyvinyl chloride manufacture factory for 35 years. An image of the biopsy is shown. What is most likely causing this lesions?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Cigarette smoking
B. Human papilloma virus
C. Molluscum contagiosum virus
D. Polyvinyl chloride
E. Sun exposure

15. A 57-year-old man presents with a ulcerated mass on his left face. He has had multiple basal cell carcinoma and melanoma. He has a 45 pack-year history of cigarette smoking and has been working in a polyvinyl chloride manufacture factory for 35 years. An image of the biopsy is shown. What is the diagnosis?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Actinic keratosis
B. Bowen disease
C. Epidermal cyst
D. Squamous cell carcinoma
E. Tricholemmoma


16. Use this case and this image for the next two questions. A 77-year-old man presents with a pruritic rash on his back. He has had similar rash a year ago that regressed without specific treatment. He has had multiple basal cell carcinomas and squamous cell carcinomas. Physical examination reveals a 3.5 cm irregular erythematous patch with fine scales at his left lower back. No other abnormality is noted. His laboratory tests results are within normal range. An image of the biopsy is shown. Initial immunohistochemistry studies reveal the cells with dark nuclei are positive for CD3, but negative for CD20. What additional markers are needed to confirm the diagnosis?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. CD4 and CD8
B. CD5 and CD23
C. CD15 and CD30
D. CK7 and CAM5.2
E. HMB45 and S100

17. A 77-year-old man presents with a pruritic rash on his back. He has had similar rash a year ago that regressed without specific treatment. He has had multiple basal cell carcinomas and squamous cell carcinomas. Physical examination reveals a 3.5 cm irregular erythematous patch with fine scales at his left lower back. No other abnormality is noted. His laboratory tests results are within normal range. An image of the biopsy is shown. Initial immunohistochemistry studies reveal the cells with dark nuclei are positive for CD3, but negative for CD20.

Additional studies reveal these cells are all positive for CD4 and negative for CD8. What is the diagnosis?
(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Dermatophytosis
B. Lichen planus
C. Mycosis fungoides
D. Psoriasis
E. Sezary syndrome


18. Use this image for this question. A 71-year-old male farmer presents with an ulcerated mass at his chest. He does not have other symptoms. He has had multiple squamous cell carcinomas and basal cell carcinomas of skin. Physical examination reveals a 4.5 cm chest mass with ulceration. No lymphoadenopathy is noted. Laboratory test is within normal range. An image of the biopsy is shown. Per immunohistochemistry studies, these cells are predominantly CD4 positive and CD8 negative. Scattered CD20 positive cells are seen in dermis. What is the diagnosis?

(Image: LWozniak&KWZielinski [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Bowen disease
B. Dermatophytosis
C. Lichen planus
D. Mycosis fungoides
E. Sezary syndrome

19. Use this case and this image for the next two questions. A 77-year-old man presents with fatigue and a 20 pound weight loss for the last two months. His past medical history is unremarkable. Physical examination reveals diffuse erythematous changes of his trunk and enlarged bilateral inguinal lymph nodes. Laboratory tests reveal a hemoglobin of 7.5 g/dl (normal 12-18 g/dl). His white cell and platelet counts are within normal range. An image of the peripheral blood smear is shown. Similar cells are seen in his lymph node biopsy. What marker is likely to be positive for these nucleated cells shown?

(Image: El*Falaf [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. CD3
B. CD11c
C. CD20
D. CD30
E. CD138

20. A 77-year-old man presents with fatigue and a 20 pound weight loss for the last two months. His past medical history is unremarkable. Physical examination reveals diffuse erythematous changes of his trunk and enlarged bilateral inguinal lymph nodes. Laboratory tests reveal a hemoglobin of 7.5 g/dl (normal 12-18 g/dl). His white cell and platelet counts are within normal range. An image of the peripheral blood smear is shown. Similar cells are seen in his lymph node biopsy. What is most likely the diagnosis?
(Image: El*Falaf [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Adult T cell leukemia
B. Chronic lymphocytic leukemia
C. Chronic myeloid leukemia
D. Hairy cell leukemia
E. Sezary syndrome


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