PT3

Practice Test 3answers can be found on page 15

1. A 69-year-old man presents with a new cough on rou-tine follow-up three years after treatment with concur-rent platinum-based chemoradiotherapy for T3, N2b,M0 squamous cell cancer of the base of the tongue onthe right side. He was rendered free of disease aftertreatment. At the time of this follow-up visit, a chestx-ray shows the interval development of a two-centime-ter nodule in the left upper lobe of the lung. He reportsno sputum production, hemoptysis, or dyspnea on exer-tion but admits to having resumed cigarette smokingapproximately two years previously.

The physical examination is entirely within normal limits.The former primary site is clean, and no neck, supra-clavicular, or axillary adenopathy is palpable.The findings of a complete blood count, serum chemistrytests, and liver function tests are within normal limits. CTof the chest shows no additional nodules, or abnormalhilar or mediastinal adenopathy. PET indicates post-treatment changes in the neck, and a lung nodule with astandard uptake value (SUV) of 9.8. Bronchoscopy withtransbronchial fine-needle aspiration of the lung massreveals poorly differentiated squamous cell cancer cellson cytologic examination.

Which of the following is the most appropriate next stepin management?

A. Palliative radiotherapy to the lung noduleB. Referral to a thoracic surgeonC. Platinum-based concurrent chemotherapy with curative-

dose radiotherapy to the lung nodule and hilar and medi-astinal lymph nodes

D. Palliative chemotherapy with paclitaxelE. Platinum-based combination chemotherapy followed by

curative-dose radiotherapy to the lung nodule and hilar andmediastinal lymph nodes

2. A 49-year-old woman is seen by her family physicianbecause of lower abdominal discomfort of three monthsduration. Physical examination and CT of the abdomenand pelvis demonstrate a large (eight centimeters by 12centimeters) pelvic mass. The lymph nodes are notenlarged, and there is no evidence of ascites. The CA-125 antigen level is 47 U/mL. During exploratory laparo-tomy, a stage 1 granulosa cell tumor is found and iscompletely resected.

Which of the following is the most appropriate next stepin the treatment of this patient?

A. Observation until relapseB. Six cycles of carboplatin plus paclitaxelC. Four cycles of cisplatin plus etoposideD. Radiation therapy to the whole abdominal cavityE. CT of the abdomen and pelvis every six months for three to

four years

3. A 60-year-old man with a 40-year history of smokingone pack of cigarettes daily presents with increasingshortness of breath over the past six months. He other-wise feels well and has no other meaningful medical his-tory. The social history is significant in that he worked ina factory fitting insulation on pipes for more than 30years before becoming a truck driver 10 years ago. Hehad been jogging two miles three or four days eachweek, but he stopped approximately three months agobecause of the shortness of breath.

A chest x-ray shows a large right-sided pleural effusion,a thoracentesis is done to remove fluid. On evaluation,the fluid is found to contain cells suspicious formesothelioma. CT of the chest shows several right-sidedpleural-based masses, no hilar or mediastinal adenopa-thy, and no parenchymal nodules. The results of pul-monary function tests include a forced vital capacity of2.5 mL. Split function tests indicate that almost all of thefunction (80%) is on the left side. The findings of pleu-ral biopsy are positive for epithelial-type mesothelioma.

Which of the following is the most appropriate treatmentfor this patient?

A. Chemotherapy and radiation therapy to the pleural-basedmasses

B. Chemotherapy and radiation therapy to the whole lung andmediastinum

C. Chemotherapy and an extra-pleural pneumonectomyD. Radiation therapy to the pleural-based masses followed by

an extrapleural pneumonectomyE. An extrapleural pneumonectomy, chemotherapy, and radia-

tion to the whole lung and mediastinum

4. Which of the following is necessary for a screeningtest to be valuable?

A. Specificity should be high and sensitivity need not beB. Sensitivity should be high and specificity need not be

Practice Test 3 | 1

C. Positive predictive value must be highD. Negative predictive value must be high

5. A 35-year-old woman was diagnosed with a 1.3-mil-limeter melanoma on the left arm. There was no ulcera-tion. Sentinel lymph node biopsy from the left axilla wasperformed, and two lymph nodes were positive formelanoma. She had a complete node dissection, and noadditional lymph nodes were positive for melanoma.

What is the risk of recurrence for this patient in the next10 years?

A. Less than 10%B. 20% to 30%C. 50% to 60%D. More than 80%

6. Some patient characteristics and behavioral factorsare associated with a higher or lower risk of breastcancer.

Which of the following is the most accurate statementabout risk factors?

A. The incidence of breast cancer is higher for women takinglong-term hormone-replacement therapy, especiallycombinations of estrogens and progestins

B. Breast cancer usually occurs in familial clusters. Havingany one relative with breast cancer increases the risk 10-fold

C. A history of ovarian cancer on the maternal side of thefamily, but not on the paternal side, is associated with afourfold increase in the risk of breast cancer

D. BRCA1 mutations are present in 12% of breast cancers;these tumors are likely to be estrogen receptor (ER)-positive and HER2-positive

E. BRCA2 mutations occur most commonly in Hispanic popu-lations and are associated with protection against breastcancer in men

7. A 53-year-old woman presents with a six-centimetermass in the upper portion of the left trapezius muscle.On surgical consultation, the mass is found to be a low-grade fibrosarcoma, deep to investing fascia. The massis removed with a minimum eight-millimeter margin inall directions.

Which of the following is the most appropriate postoper-ative treatment for this patient?

A. Adjuvant chemotherapy onlyB. Adjuvant radiation therapyC. Both adjuvant chemotherapy and adjuvant radiation therapy

D. Clinical follow-up and no further intervention at the presenttime

8. A 50-year-old man is seen after the first cycle of infu-sion fluorouracil, leucovorin, and irinotecan for metasta-tic colon cancer. During this first cycle, which was giventwo weeks ago, he had grade 4 diarrhea that necessi-tated intensive loperamide therapy and intravenous fluidreplacement beginning four days after the infusionswere started and lasting for five days. The results of acomplete blood cell count showed a total white bloodcell count of 1,200/L with an absolute neutrophil countof 450/L, a platelet count of 175,000/L, and a hema-tocrit of 36 g/dL. He has had no mucositis, nausea,vomiting, fever, blood in the stool, or rash. The results ofbaseline liver and renal function studies (obtainedbefore the first cycle of treatment) were normal, includ-ing a total bilirubin of 0.9 mg/dL.

Which of the following would you recommend, once theneutrophil count recovers to a normal value?

A. Re-treat the patient at the same doses but give G-CSF afterthe infusion ends

B. Give no additional fluorouracil, as the the patient may bedihydropyrimidine dehydrogenase deficient

C. Give capecitabine instead of the fluorouracil-based combi-nation, as the patient may be dihydropyrimidine dehydroge-nase deficient

D. Use oxaliplatin instead of irinotecan, as the patient may beUGT1A1 deficient

E. Reduce subsequent doses of irinotecan, as the patient maybe UGT1A1 deficient

9. A 55-year-old man presents for advice about his riskof gastric cancer. He had been seen initially by hisprimary care physician because of epigastric discomfortthat was relieved by food and that increased at nightwhen he was in bed. On most occasions, the symptomswere relieved by the use of over-the-counter H-2 antag-onists and calcium carbonate, but persistent pain andincreasing discomfort led to upper endoscopy, andpatches of erythema and one shallow ulcer were seen.The findings on biopsy specimens were negative forcancer but positive for Helicobacter pylori. His primarycare physician is treating him with proton-pumpinhibitors and antibiotics to eradicate the H. pylori.

Which of the following do you tell him?

A. You agree with treating the H. pylori because it willdecrease the risk of gastric cancer

B. You agree with treating the H. pylori because it willdecrease the risk of further peptic ulcer disease andgastric cancer

2 | Practice Test 3

C. You agree with treating the H. pylori because it willdecrease the risk of further peptic ulcer disease, but it willnot decrease the risk of stomach cancer

D. You disagree with treating the H. pylori because the riskassociated with the antibiotics is greater than the benefit

10. A 50-year-old man presents with a two-month his-tory of intermittent painless hematuria. He also feelsfeverish. The body temperature is 37.8C. A completeblood count reveals microcytic hypochromic anemia. Ablood chemistry panel indicates the following levels:alkaline phosphatase, 245 U/L; aspartate aminotrans-ferase, 80 U/L; alanine aminotransferase 90 U/L; andlactate dehydrogenase (LDH) 600 U/L. CT of theabdomen shows a mass in the lower pole of the left kid-ney. CT of the chest demonstrates a four-centimetermetastatic lesion on the left lung and two two-centime-ter metastases in the right lung.

With reference to this patients probable renal cancer,which of the following is false?

A. A mutated VHL gene is commonly foundB. IL-2 (aldesleukin) and IFN-2 have shown activity in

metastatic renal cell cancerC. The temperature elevation may be the result of an increase

in serum IL-1 or IL-6D. Resection of the primary tumor and administration of IFN-

2 may improve survival even for patients with metastaticdisease

E. IL-2 has been shown to prolong the median survival ofpatients with metastatic renal cell cancer

11. A 52-year-old man presents for the first time for aroutine physical examination and is found to have aPSA level of 4.1 ng/mL. He has no urinary symptomsor erectile dysfunction. No abnormalities are found onphysical examination. On digital rectal examination,the prostate appears to be of normal size with noabnormalities. There are no associated medicalcomorbidities.

Which of the following would you advise for the patientat this point?

A. Repeat PSA testB. Transrectal ultrasound-guided biopsy of the prostateC. Free PSA testD. CT scan of the abdomen and pelvis, and a bone scanE. Follow-up evaluation in one year

12. Which of the following is a risk factor for the car-diotoxicity associated with arsenic trioxide?

A. History of coronary artery disease

B. History of congestive heart failureC. Prior radiation therapy to the thoraxD. HypocalcemiaE. Extensive previous treatment with anthracyclines

13. A 37-year-old man presents with a left testicularmass. He has a remote history of having had a subtotalcolectomy with ileorectal anastamosis. Two years beforepresentation he had a right ureteral obstruction and wasfound to have a retroperitoneal mass that changed littleover time. A stent was placed. Testicular ultrasound con-firms a mass. A left inguinal orchiectomy is carried out.

Which of the following is the most likely histologic typeof the testicular mass?

A. TeratomaB. SeminomaC. Leydig cell tumorD. Mixed germ cell tumorE. Lymphoma

14. With regard to the patient described in question 13,which of the following is the cause of the right ureteralobstruction?

A. Congenital malformationB. LymphomaC. Metastatic germ cell tumor to retroperitoneumD. DesmoidE. Low grade sarcoma

15. For the patient described in question 13, which ofthe following molecular tests should be conducted tohelp elucidate the underlying cause of all of the prob-lems?

A. Southern blottingB. Protein truncation assayC. Microsatellite instability assayD. Taqman assayE. cDNA microarray analysis

16. With regard to the patient described in question 13,which of the following loci is the site of the geneticabnormality?

A. 5qB. 9qC. 17pD. 8qE. 5p

17. With regard to the patient described in question 13,which of the following medications should be used?

3Practice Test 3 |

A. MethotrexateB. FinasterideC. CisplatinD. Oral etoposideE. Celecoxib

18. Which approach to previously untreated patientswith follicular non-Hodgkins lymphoma has been asso-ciated with prolonged survival in randomized studieswhen compared with an alkylating agent-based regi-men?

A. CHOP plus rituximabB. CHOPC. Fludarabine and mitoxantroneD. None of the above

19. A 60-year-old woman had a right upper lobectomyfor a T2, N1, M0 adenocarcinoma of the right lung oneyear ago. She had no other treatment for the lung can-cer. She presents now with gradual onset of increasingheadache and slight weakness of the left upper extrem-ity over the past three to four weeks. On physical exami-nation, there is minimal left upper extremity neglect andparesis. She has stable diminished breath sounds, noadenopathy, and no other physical findings indicative ofmetastases. MRI of the head demonstrates a solitary,uniformly contrast-enhanced mass lesion at the junctionof gray and white matter in the right frontal lobe.CT scans of the chest and upper abdomen show noevidence of metastatic lung cancer. The presumptivediagnosis is metastatic lung cancer.

Based on the presumptive diagnosis, which of thefollowing therapeutic approaches is most likely to extendher life and reduce the risk of long-term neurologicdeterioration?

A. Corticosteroids and observationB. Whole-brain radiation therapyC. Surgical excision and observationD. Surgical excision and whole-brain radiation therapyE. Surgical excision and adjuvant chemotherapy

20. A 56-year-old man presents with a persistent cough,dyspnea, and an elevated eosinophil count. Six monthsearlier, an elevated eosinophil count was noted on rou-tine screening but no work-up was performed. The cur-rent white blood cell count is 25 x 103/L, with 40%eosinophils and no peripheral blasts. Examination of thebone marrow shows hypercellular marrow witheosinophils or their precursors constituting 50% of themarrow elements. The patient takes no medications,

and multiple stool samples are negative for evidence ofparasitic infection.

Which of the following therapies is most likely to result ina complete response for this patient?

A. Gemtuzumab B. Imatinib mesylateC. All-trans retinoic acidD. IFN-E. Cyclosporine

21. Endocrine therapy is indicated for the treatment ofmany patients with metastatic breast cancer.

Which of the following statements is false?

A. Endocrine therapy is indicated only for patients with ER positive or PR positive metastatic disease

B. Ovarian ablation is indicated only for premenopausalpatients

C. Aromatase inhibitors have not been adequately tested forpremenopausal women or men with breast cancer

D. Women with high endogenous estrogen levels do not havea response to tamoxifen

E. Overexpression of HER2 appears to be associated withrelative resistance to tamoxifen

22. A 78-year-old woman has a lumpectomy and axillarydissection for breast cancer. The primary tumor meas-ures 3.5 centimeters in maximum dimension, is ER neg-ative, PR negative, and HER2 negative. The margins ofresection are free of cancer. Two of 10 lymph nodes wereinvolved with cancer. The patient is in excellent health,with the exception of mild hypertension for which shetakes hydrochlorthiazide. She is widowed and lives in thehome she shared with her husband for 35 years.

You recommend radiation therapy to the breast. Inaddition, which of the following would you tell the patient?

A. Anastrozole is more effective than tamoxifen, given thestage of disease

B. Adjuvant tamoxifen should be prescribedC. Adjuvant chemotherapy will decrease the likelihood of

cancer recurrenceD. No additional systemic therapy is warrantedE. The regional lymph nodes should be included in the

radiation field

23. A 43-year-old man has a 3.2-millimeter melanoma onthe left part of the chest wall. On sentinel node dissection,the left axillary node is found to be positive for disease. Acomplete left axillary dissection is done, and 10 of 12

4 | Practice Test 3

nodes are found to be positive for metastatic disease. Hehas no evidence of metastatic disease on CT of the chest,abdomen, and head.

Which of the following would be a reasonable recom-mendation to him?

A. One year of high-dose IFN-2B. One year of high-dose IL-2 (aldesleukin)C. Prophylactic right axillary node dissectionD. Prophylactic radiation to the central nervous systemE. Three monthly cycles of temozolomide, 200 mg/m2 daily

for five days

24. A 52-year-old man had a radical cystectomy with cre-ation of an internal urinary reservoir for a T4, node-posi-tive transitional cell tumor. Two of 12 lymph nodes werepositive for metastatic disease. One year after the sur-gery, three pulmonary lesions were identified in the rightlung, which were metastatic transitional cell cancer. Thepatient received three cycles of systemic chemotherapywith gemcitabine and cisplatin, which produced a 60%reduction in the size of the pulmonary lesions. Threeadditional cycles of therapy were then administered withno additional changes in the size of the lesions.

Which of the following would you recommend?

A. Add single-agent paclitaxelB. Continue the same chemotherapy regimenC. Surgically resect the metastatic lesionsD. Change to the M-VAC regimenE. Change to a combination of paclitaxel and carboplatin

25. A 56-year-old nonsmoking woman presents with athree-month history of cough and shortness of breath.Over the past four weeks, the cough has produced copi-ous amounts of sputum. The medical history is signifi-cant for hypertension. On physical examination, she hasfine, bilateral rales. A chest x-ray shows diffuse, bilateralparenchymal nodules. CT of the chest demonstrates nomediastinal or hilar adenopathy and no signs of metas-tases in the liver or adrenal glands. Thoracotomy is per-formed, and one of the nodules is obtained by biopsy.On evaluation, the nodule is positive for bronchioalveo-lar cancer.

Which of the following is the most appropriate therapyfor this patient?

A. GemcitabineB. Gemcitabine and carboplatinC. Gemcitabine, carboplatin, and paclitaxelD. GefitinibE. Gemcitabine, carboplatin, and gefitinib

26. A 28-year-old homosexual man with known historyof cutaneous Kaposis sarcoma and HIV infection pres-ents with progressive shortness of breath and a drycough that has worsened over the preceding threemonths. He has been on antiretroviral therapy for eightyears but has a history of noncompliance. The HIV viralload fluctuates from less than 500 copies/mL to asmuch as one million copies/mL. The patient receivedlocal therapy for cutaneous Kaposis sarcoma withresponse by the treated lesions. The lesions began toimprove substantially during the use of highly activeantiretroviral therapy. However, they began to recur overthe past eight months, associated with noncomplianceand a declining CD4 count. A chest x-ray shows bilateraleffusions, more on the right side than on the left. Fluidobtained by thoracentesis is pink-tinged, with no evi-dence of infection on extensive evaluation. Evaluation ofpleural tissue obtained by biopsy confirmed the diagno-sis of pulmonary Kaposis sarcoma. Tissue staining forHHV-8 was positive along with a high serum titer.

With which of the following diseases is HHV-8 associated?

A. Classic Kaposis sarcomaB. Endemic Kaposis sarcomaC. Renal transplant-associated Kaposis sarcomaD. HIV-associated/epidemic Kaposis sarcomaE. All of the above

27. Referring to the patient described in question 26,which one of the following is the most appropriate treat-ment option for this patient?

A. Highly active antiretroviral therapyB. InterferonC. ThalidomideD. Chemotherapy with an anthracycline-based regimenE. Chemotherapy using cisplatin or other platinum-based

regimen

28. A 35-year-old woman presents with a primary symp-tom of abnormal vaginal bleeding. Pelvic examinationand the findings on analysis of a biopsy specimen indi-cate a squamous cell malignant lesion, which, on furtherevaluation, is found to be a stage IIB cervical cancer.

Which of the following is the most appropriate next stepin the treatment of this patient?

A. External beam radiation therapyB. Six cycles of cisplatin and paclitaxelC. Three cycles of cisplatin and fluorouracil followed by

radiation therapy to the pelvisD. External beam radiation therapy followed by five cycles of

cisplatin and ifosfamide

5Practice Test 3 |

E. External beam radiation therapy plus with weeklycisplatin

29. During an evaluation for pneumonia, a 42-year-oldpremenopausal woman is found to have a large mass(seven centimeters by nine centimeters) in the leftbreast. The mass does not involve the skin or underly-ing structures. There are multiple enlarged, firm, ipsi-lateral axillary lymph nodes. The findings ofcore-needle biopsy demonstrate an infiltrating ductalcancer, nuclear grade 3, that is ER negative, PR nega-tive, and HER2 negative. Staging work-up does notindicate distant metastasis.

Which of the following is the most appropriate therapeu-tic plan?A. Lumpectomy and axillary dissection followed by four cycles

of AC followed by radiation therapy to the breast followedby tamoxifen for five years

B. Modified radical mastectomy with sentinel lymph nodebiopsy followed by four cycles of mitoxantrone andcyclophosphamide and goserelin for two years

C. Four cycles of FAC followed by surgical resection followedby four cycles of a taxane

D. Four cycles of FAC followed by surgical resection followedby four cycles of a taxane and followed by radiation ther-apy

E. Subcutaneous mastectomy with placement of a breastimplant, followed by radiation therapy, goserelin for twoyears, and trastuzumab for one year

30. The new WHO classification of MDS differs from thepreviously used French-American-British (FAB) Classi-fication in several important ways.

Which of the following is not one of the differences?

A. Removal of refractory anemia with excess blasts from theMDS categories

B. Reduction in the number of blasts to make the diagnosis ofAML from 30% to 20%

C. Reclassifying chronic myelomonocytic leukemia as amyeloproliferative disorder

D. Inclusion of a new category of refractory anemia withtrilineage dysplasia

31. Which of the following is true about yttrium-90-labeled (90Y)-ibritumomab tiuxetan radioimmunother-apy for follicular, low-grade non-Hodgkins lymphoma?

A. It induces higher rates of complete response and overallresponse than rituximab, with a longer time to progressionbut no impact on survival

B. It can be given safely to patients in whom less than 50%of the bone marrow is involved with disease

C. It achieves response in more than 60% of patients whohave disease that relapsed or was refractory to rituximabtherapy

D. Myelosuppression generally occurs 10 to 14 days after thetherapeutic dose

32. Which of the following provides the strongest evi-dence that a cancer screening test is beneficial?

A. Increased five-year survival of those screened comparedwith historical controls

B. Earlier stage at time of diagnosis for those screenedcompared with those not screened

C. Large numbers of so-called cured patients who die ofcauses other than cancer

D. Decreased cause-specific mortality for those in thescreened arm compared with those in the control arm of arandomized clinical trial

33. A 57-year-old man with prostate cancer that ismetastastic to the bone has been placed on hospiceafter a decision by his medical oncologist, radiationoncologist, and surgical oncologist to discontinue antitu-mor therapy. He had been treated with surgery, radiationtherapy, and chemotherapy.

Immediate-release morphine sulphate has been pre-scribed at a dose of 30 mg every four to six hours asneeded for pain. He has been taking an average of 120mg daily for the past several days. He is tolerating it wellbut still having substantial pain, with an average score of7 on a pain scale of 0 to 10.

A decision is made to prescribe sustained-release mor-phine at a dose of 90 mg orally twice a day. An appro-priate bowel regimen is prescribed in an effort preventconstipation. In addition to the sustained-release mor-phine, his physician decides to provide an as-needed,30-mg dose of immediate-release morphine.

At which of the following intervals should this as needed,immediate-release morphine be available for the patientto take for unrelieved pain?

A. Every 15 minutesB. Every one hourC. Every three hoursD. Every four hours

34. A 41-year-old man has been diagnosed withAML. The white blood cell count is 30 x 103/L andcytogenetic analysis shows t(8;21). A complete remis-sion is achieved with treatment with daunomycin and

6 | Practice Test 3

standard-dose cytarabine. He has no human leukocyteantigen (HLA)-matched siblings.

According to the results of randomized trials, which ofthe following would prolong the duration of completeremission considerably for this patient?

A. CNS prophylaxis with intrathecal methotrexate and cranialradiation

B. Maintenance therapy with low-dose IL-2C. Consolidation therapy with multiple cycles of high-dose

cytarabineD. Maintenance therapy with all-trans retinoic acidE. Maintenance therapy with imatinib mesylate

35. Some behavioral characteristics have been associ-ated with a higher or lower risk of breast cancer.

Which of the following statements is true?

A. Strenuous physical activity enhances endogenous produc-tion of estradiol rather than estrone and, thus, increasesthe risk of breast cancer

B. Obesity in premenopausal women is associated with a four-fold increase in the risk of breast cancer

C. Obesity is not a risk factor for postmenopausal womenD. Long-term intake of combined estrogen-progestin hormone-

replacement therapy reduces by 50% the risk of breastcancer

E. Regular consumption of alcoholic beverages, even one ortwo drinks daily, significantly increases the risk of breastcancer

36. A 45-year-old man presents to his primary care physi-cian because of darkening urine, mild pruritis, and hiswifes concerns about his color. A review of systems waspositive for low-level back pain, mild early satiety, and a15-pound weight loss in the past two months. The physi-cal examination revealed scleral icterus, hepatomegaly,and bilateral edema (1+) in the lower extremities. CTdemonstrated biliary constriction, a five-centimeter massin the pancreatic head, and multiple lesions (two to fourcentimeters) on the liver. Endoscopic retrograde cholan-giopancreatography (ERCP) allowed for the placement ofa biliary stent, resulting in the normalization of the jaun-dice and pruritis. Oxycodone, 5 mg every six hours wasstarted for the back pain. Brushings obtained during theERCP were positive for a cluster of poorly differentiatedadenocarcinoma. The patient and his wife now present toyou for treatment advice. He has a performance status of90%, pain is controlled, and he continues to work but hasreduced his hours to part-time.

Which of the following would you recommend?

A. Gemcitabine as single-agent chemotherapyB. Initial radiation therapy to the primary pancreatic tumor,

given concurrently with chemotherapy, followed bygemcitabine as single-agent therapy

C. Gemcitabine and fluorouracil combination chemotherapyD. Gemcitabine and oxaliplatin combination chemotherapyE. No therapy and referral to hospice

37. A 24-year-old man presents with a left testicularmass that was resected by radical orchiectomy. The pre-operative level of HCG was 224 IU/mL. Pathologic eval-uation of the resected specimen showed embryonalcancer with vascular invasion. The HCG level 10 daysand 20 days after surgery were 224 IU/mL and 110IU/mL. The alpha-fetoprotein level is within normal lim-its. The findings on CT of the chest and abdomen, donebefore surgery, were normal.

Which of the following would you advise?

A. Four cycles of bleomycin, etoposide, and cisplatinB. A nerve-sparing retroperitoneal lymph node dissectionC. Three cycles of etoposide and cisplatinD. Radiation therapy to the abdomenE. Observation

38. A 60-year-old man presents with a six-week historyof cough, shortness of breath, fatigue, anorexia, and a15-pound weight loss. In reviewing symptoms, hereports that he also has headaches and a vague right-sided abdominal pain. He has smoked two packs of cig-arettes daily since the age of 15. On physicalexamination, he appears cachetic and ill; his perform-ance status is 2. You notice some swelling of the rightarm and venous distension of anterior chest wall veins.A chest x-ray shows a large mass in the right upper lobe.The preliminary findings of percutaneous biopsyconfirm small cell lung cancer. The results of CT of thechest demonstrate the mass compressing the superiorvena cava, as well as bulky, right-sided mediastinaladenopathy and liver metastasis.

Which of the following is the appropriate initial manage-ment of this patient?

A. Observation until the final results of the biopsy are avail-able

B. Emergency radiation therapy to the thoraxC. ChemotherapyD. Stenting of the superior vena cava, followed by radiation

therapy to the thoraxE. Stenting of the superior vena cava, followed by chemotherapyF. Radiation therapy to the thorax followed by

chemotherapy

Practice Test 3 | 7

39. Referring to the patient described in question 38,given his performance status of 2 (Karnosky perform-ance status of 60%), which of the following is theoptimal systemic treatment?

A. Single-agent paclitaxelB. Single-agent etoposideC. Single-agent carboplatinD. Carboplatin and paclitaxelE. Carboplatin and etoposide

40. A 38-year-old woman with stage III diffuse large celllymphoma in second remission is scheduled for autolo-gous transplantation following a preparative regimen ofcyclophosphamide and total-body radiation.

With regard to the choice of bone marrow versus GCSF-mobilized peripheral blood as a source of stem cells forsuch patients, which of the following has been demon-strated in prospective randomized trials?

A. Peripheral blood is less likely to be contaminated bytumor

B. Peripheral blood leads to a decreased incidence of relapseafter transplantation

C. Peripheral blood leads to improved disease-free survivalD. Peripheral blood leads to faster myeloid and platelet count

recoveryE. All of the above

41. A 70-year-old woman describes symptoms of feversand night sweats, a diffuse rash, and some arthralgias.On physical examination, in addition to the macularrash, there is diffuse lymphadenopathy and mildhepatosplenomegaly. The findings of laboratory testinginclude a hemoglobin of 9.8 g/dL, a hematocrit of 31%,and normal white blood cell and platelet counts. Furtherassessment reveals hypergammaglobulinemia, a lactatedehydrogenase (LDH) level of 460 U/L, and an erythro-cyte sedimentation rate of 78 mm/hr. She also has pos-itive results on Coombs testing.

The results of fine-needle biopsy of one of the lymphnodes are nondiagnostic. The findings on excisionalbiopsy are notable for partial effacement with decreasedB-cell follicles. There is vascular proliferation with perivas-cular, atypical, medium-sized lymphoid cells, as well aseosinophils and plasma cells, with Reed-Sternberg-likecells. Immunohistochemistry results are CD3+, CD4+,CD8+, and CD10+, with proliferation of follicular dendriticcells (CD21+). The bone marrow is also involved.

Which of the following is the most likely diagnosis?

A. Angioimmunoblastic T-cell lymphoma

B. Anaplastic large T-cell lymphomaC. Hodgkins lymphomaD. Mycosis fungoidesE. Reactive hyperplasia

42. Oncogene abnormalities have gradually been shownto have prognostic importance and have been used toguide choice of treatment.

Which of the following oncogenes would not affect treat-ment decisions?

A. HER2B. BCR-ABLC. P53D. PDGFRBE. KIT

43. Which of the following statements is not true aboutrituximab?

A. It induces response in approximately 50% of patients withrelapsed or refractory follicular, low-grade non-Hodgkinslymphoma

B. It may enhance the myelotoxicity associated withchemotherapy

C. It can induce a second response in approximately 40% ofpatients with follicular lymphoma who had a previousresponse to rituximab

D. It induces a response in approximately 50% of cases ofrelapsed or refractory CLL

44. You are treating a 55-year-old woman with stage III(node-positive) melanoma, and you recommend high-dose interferon.

Which of the following side effects of treatment wouldyou discuss with her?

A. Fever, hair loss, congestive heart failure, and diarrheaB. Myalgia, numbness and tingling, and chillsC. Fever, chills, depression, neutropenia, and abnormal liver

function testsD. Neutropenia, peripheral edema, and pleural effusionE. Constipation and myelosuppression

45. Which of the following cancers is not associated witha moderate to high frequency of P53 mutations?

A. Squamous cell cancer of the head and neckB. Breast cancerC. Lung cancerD. Colon cancerE. Bladder cancer

8 | Practice Test 3

46. A 47-year-old woman presents with right flank pain.She has no associated fever, chills, or weight loss. Thefindings on physical examination are remarkable for apalpable mass in the right upper quadrant. No cos-tovertebral angle tenderness is noted. The results of lab-oratory tests include hemoglobin, 11 g/dL; alkalinephosphatase, normal; aspartate aminotransferase, 180U/L; lactate dehydrogenase, 300 U/L; and partialthromboplastin time, 1.5 times normal.

Diagnostic studies show a right-sided mass originatingin the kidney, with a question of extension into theperirenal fat. There is no adenopathy and no evidenceof invasion into the inferior vena cava. No focal abnor-malities were observed in the liver.

Which of the following should be included in the man-agement of disease?

A. Bone scanB. Intravenous pyelographyC. Resection of the right renal massD. IFN-E. IL-2 (aldesleukin)

47. A 60-year-old woman is scheduled to receive cisplatin-based chemotherapy. As such, her physician plans to giveher a serotonin-3 receptor antagonist as an antiemetic.

Which of the following is recommended, in terms ofroute and frequency of administration of one of theorally available serotonin-3 receptor antagonists(ondansetron, granisetron, or dolasetron)?

A. Orally; one dose per dayB. Orally; two doses per dayC. Intravenously; two doses per dayD. Intravenously; three doses per day

48. Which of the following best describes a pharmaco-dynamic endpoint?

A. The relationship between an administered dose and themaximum plasma concentration achieved

B. The relationship between an administered dose and anobserved toxicity

C. The pharmacokinetic interaction of two drugs administeredsimultaneously

D. The relationship of an administered dose of a drug and achange in a biologic target

E. The pharmacokinetic impact of a drug on the clearancemechanisms in a patient

49. A 63-year-old man presents with pain in the lowerback. Compression fractures of the vertebrae are seen

on x-rays. Additional findings include a hemoglobin of10.0 g/dL, an IgG level of 3,500 mg/dL, a serum calciumlevel of 10.9 mg/dL, and a uric acid level of 2.7 mg/dL.Evaluation of bone marrow aspirate and of tissueobtained by biopsy indicate sheets of plasma cells. Theresults of a bone scan are remarkable for numerous lyticbone lesions. The diagnosis of multiple myeloma ismade. Chemotherapy is started with a combination ofvincristine, dexamethasone and doxorubicin.

Which of the following treatments should be used inaddition to the chemotherapy?

A. Prophylactic antibioticsB. Prophylactic intravenous immunoglobulinsC. BisphosphonateD. Radiation therapy to the area of back pain

50. A patient with advanced incurable cancer has beenplaced on hospice and is being treated at home, withsubstantial support from an extended family. Thepatient had been remarkably comfortable but, over thepreceding week, has become weaker. As a result ofhepatic insufficiency, the patient became comatose twodays ago. He did not appear to be in any pain and wasbreathing comfortably. Over the past 12 hours, how-ever, a gurgling sound developed in the back of histhroat with respirations. He does not appear to becoughing or to be otherwise uncomfortable, but thefamily is distressed about whether the patient isdrowning in his own secretions. They ask if some-thing can be done.

Which of the following would you recommend to dry thesecretions to treat this so-called death rattle?

A. Ativan (lorazepam) B. PropranololC. Dexamethasone D. Atropine

51. A 28-year-old woman recently had a mole removedfrom the back (Fig. 1). She described it as light brownin color and as having increased in size over the pastyear. On physical examination, there are numerous flatlight brown to dark moles over the trunk, which range insize from seven to 15 millimeters. Biopsy results indi-cate a dysplastic nevus with mild atypia, the lesion didnot extend to the margins. Her family history is remark-able for a paternal uncle with a history of melanoma anda father with numerous moles.

What would you recommend for this patient?

A. Wide excision of the biopsy site, with one to two-centime-ter margins

Practice Test 3 | 9

B. No further surgery, but continue follow-up with periodicskin examinations

C. Wide excision of the original lesion with one to two-centimeter margins and excision of all the remaining moleson her trunk

D. Local radiation therapy to the biopsy siteE. Liquid nitrogen freezing at the biopsy site

52. A total of 100 patients are screened for cancer using anewly developed screening test with the following results: 8 results are truly positive 1 result is falsely positive 1 result is falsely negative 90 results are truly negative

Which of the following formulas is used to determine thesensitivity of the test?

A. 90 divided by (1 + 90)B. 8 divided by (90 + 1)C. 90 divided by (90 + 8)D. 8 divided by (8 + 1)

53. Which of the following statements about CNS pro-phylaxis in adults is correct?

A. Because the incidence of CNS disease for adults is somuch lower than that that for children, there is no need forprophylaxis in adults.

B. Although the risks for CNS recurrence are lower for adultsthan for children, prophylaxis is still indicated for alladults.

C. Because the incidence of CNS disease is lower for adults,prophylaxis is only indicated for patients with an increasedrisk of CNS disease, specifically individuals with a high

white count at diagnosis or a high lactate dehydrogenaselevel.

D. Because the toxicities of prophylaxis are so much greaterfor adults than for children, only those adults with a highrisk of CNS recurrence should receive it.

54. A 64-year-old woman presented with a three-cen-timeter mass on the hard palate that was found to beadenoid cystic cancer on examination of a biopsy spec-imen. No cranial nerve palsies or focal neurologic find-ings were present, particularly in the head and neck.Complete evaluation for disease demonstrated no dis-ease in the neck and no suspicion of disease at a distantsite. After primary surgical treatment, postoperativeradiotherapy was administered because of concern forthe adequacy of the superior surgical margin. The radi-ation field included nerve pathways to the base of skull.A palate prosthesis resulted in good speech and swal-lowing function. The patient was rendered free ofdisease.

Four years after completing therapy, she returns to youroffice with a chest x-ray from her primary care physicianthat shows a possible left lung nodule, which is new com-pared with an x-ray made six months previously. She isentirely asymptomatic, without fever, cough, or hemopt-ysis, and she continues to work full-time. She knows ofno toxic exposure. Physical examination, including eval-uation of the original primary site, is normal. The resultsof a complete blood count, serum chemistry tests, andliver function tests are within normal limits. CT of thechest confirms a one-centimeter nodule in the left lowerlobe, as well as approximately 10 additional subcentime-ter bilateral pulmonary nodules. A thorascopic biopsywas performed. Two nodules were removed, both show-ing metastatic adenoid cystic cancer.

Which of the following is the most appropriate next stepin management?

A. Treatment with imatinibB. Chemotherapy with cyclophosphamide, doxorubicin, and

cisplatinC. Immunotherapy with interferon-alphaD. Watchful waiting with serial imaging of the chestE. Referral to thoracic surgeon for staged bilateral thoraco-

tomy and metastectomy

55. A 59-year-old woman who has taken combinedhormone-replacement therapy since the onset ofmenopause eight years earlier has abnormal findings onscreening mammogram. Clusters of suspicious calcifi-cations are identified, covering a 1.2-centimeter area of

10

Figure 1. Mole on the back of the patient described in question 51. Each lineindicates one millimeter.

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the lower, inner quadrant of the right breast. The resultsof needle-localization biopsy indicate DCIS, 1.3 cen-timeters in largest diameter, that is nuclear grade 2. Themedial margin is positive for disease. The ER assay isnegative.

Which of the following is the most appropriate treatmentplan?

A. Modified radical mastectomyB. Bilateral subcutaneous mastectomyC. Lumpectomy with clear surgical margins and radiation

therapy to the breastD. Lumpectomy and axillary dissection, radiation therapy to

the breastE. Lumpectomy alone

56. An 87-year-old woman is seen because of shortnessof breath, abdominal pain, and bloating. The patientlives with her granddaughter and had been fairly inde-pendent in her daily activities. However, for the last fewweeks she has spent most of the day in bed. The patienthas medication-controlled hypertension and adult-onsetdiabetes. She had a minor stroke four years ago, fromwhich she recovered completely.

On physical examination, breath sounds are decreasedat both lung bases, and there is marked ascites. Thefindings of computerized tomography of the abdomenand pelvis confirm the presence of ascites and showsdiffuse carcinomatosis. There is also evidence of a largepelvic mass that is consistent with an ovarian neoplasm.The CA-125 antigen level is 5,700 U/mL. A paracente-sis is performed, with removal of five liters of fluid. Thefindings of cytologic analysis of the peritoneal fluid indi-cates adenocarcinoma.

Which of the following is the most appropriate next stepin the treatment of this patient?

A. A combination regimen consisting of a platinum agent anda taxane, delivered without dose modifications and (ifnecessary) with bone marrow growth factor support

B. Single-agent carboplatin followed by paclitaxel if theresponse is inadequate

C. Single-agent paclitaxelD. A regimen of carboplatin and a taxane followed by high-

dose chemotherapyE. No chemotherapy

57. Which of the following is true regarding cigarettesmoking and cancer?

A. Almost all lung cancer occurs in people who are activesmokers

B. Smoking low-tar and nicotine cigarettes reduces the risk oflung cancer but not heart disease

C. The risk of lung cancer for smokers who quit decreases toclose to the baseline in 20 years, although it may notreach zero

D. Exposure to asbestos is a risk factor for mesothelioma butnot lung cancer

E. Although smoking is associated with an increased risk ofsmall cell, large cell, and squamous cell cancers, it is notassociated with an increased risk of adenocarcinoma

58. A 42-year-old man presents four weeks after suc-cessful partial gastrectomy for adenocarcinoma of thestomach because his surgeon has suggested the needfor chemotherapy. Preoperative staging after diagnosticupper endoscopy was negative for metastatic disease.He recovered well after the surgery, with his weight sta-bilizing. (He had had a 15-pound weight loss at thetime of initial presentation.) Pathologic evaluation of thesurgical specimen demonstrates a transmurally pene-trating, moderately differentiated adenocarcinoma, andone of 15 lymph nodes is positive for metastaticdisease. The proximal margin is read as close butnegative (one centimeter). The findings of physicalexamination are normal, including a well-healed mid-line scar.

Which of the following would you recommend?

A. No further treatmentB. Radiation therapy to the upper abdomen with fluorouracil

as a radiation synergizerC. Adjuvant chemotherapy with fluorouracil and cisplatin for

four to six monthsD. Chemotherapy with fluorouracil plus leucovorin for one

cycle followed by combined radiation therapy and fluo-rouracil followed by three more cycles of fluorouracil plusleucovorin

E. Adjuvant chemotherapy with fluorouracil for six months

59. Monoclonal antibodies, a biologic therapy, target tumorproteins with the selectivity and specificity that character-ize immune responses.Their therapeutic usefulness has now been shown in all ofthe following disseminated malignant processes exceptwhich of the following?

A. MelanomaB. AMLC. CLLD. Breast cancerE. Follicular B-cell lymphomas

Practice Test 3 | 11

60. A 54-year-old postmenopausal woman is seen inconsultation after the diagnosis and surgical removal of a0.8-centimeter invasive lobular cancer of the right breastthat was ER positive, PR positive, and HER2 negative.She had deep-vein thrombosis 18 months earlier.Lumpectomy was carried out with clear surgical marginsand two sentinel lymph nodes had no disease. Plannedtreatment will include radiation therapy to the breast.

Which of the following systemic treatment strategieswould you recommend?

A. Tamoxifen for five years, followed by letrozole for five yearsB. Tamoxifen for five yearsC. Six cycles of FEC followed by anastrozole for five yearsD. Anastrozole for five yearsE. Four cycles of AC

12 | Practice Test 3