Oncology Practice Questions

Q: A 55-year-old man presents with fatigue and splenomegaly. His complete blood count reveals a marked increase in mature lymphocytes. What condition is consistent with these findings?

Chronic lymphocytic leukemia. ***Chronic lymphocytic leukemia*** - Characterized by a marked increase in **mature lymphocytes** and often presents with **fatigue and splenomegaly** [1][2]. - Typically seen in older adults, with a **slow progression** and lymphocytic predominance in the blood and bone marrow [2]. *Acute myeloid leukemia* - Presents with **immature myeloid cells** and often involves severe **anemia**, thrombocytopenia, and neutropenia. - Symptoms frequently include **rapid onset of fatigue** and bleeding, not typically splenomegaly as a primary feature. *Acute lymphoblastic leukemia* - Characterized by **immature lymphoblasts** rather than mature lymphocytes, leading to more aggressive symptoms. - Often presents with **bone pain**, lymphadenopathy, and more severe cytopenias, different from the chronic features noted here. *Chronic myeloid leukemia* - Features an increase in **myeloid cells**, particularly **granulocytes**, and is commonly associated with the **Philadelphia chromosome**. - Splenomegaly is common [3][4], but it primarily involves a **myeloid lineage**, not mature lymphocytes as seen in this case. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 602. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 612-613. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 611-612. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 625-626.

Q: A patient with known breast cancer presents with shortness of breath. A chest CT reveals multiple nodules throughout both lungs. What is the most likely diagnosis?

Metastatic disease. Metastatic disease - The presence of **multiple lung nodules** in a patient with a known history of **breast cancer** strongly suggests hematogenous spread to the lungs [1]. - Breast cancer frequently metastasizes to the lungs, and these **multiple, widespread nodules** are a classic presentation of such progression [1]. Patients with two or more pulmonary nodules can often be assumed to have metastases [2]. *Primary lung cancer* - While lung cancer can manifest as nodules, the presence of **multiple, scattered nodules in both lungs** in a patient with an existing primary cancer makes this less likely to be a *de novo* primary lung cancer. - Primary lung cancer typically presents as a **single mass** or a more localized process, although multifocal primary lung cancers can occur, they are less common than metastatic disease in this context [2]. *Pneumonia* - Pneumonia would typically present with **infiltrates or consolidation**, often associated with fever, cough with sputum, and elevated inflammatory markers. - **Multiple, discrete lung nodules** are not a typical presentation of pneumonia. *Pulmonary embolism* - Pulmonary embolism causes **filling defects** in the pulmonary arteries and can lead to infarcts, which might appear as wedge-shaped opacities, but usually not as **multiple, diffuse nodules** throughout both lungs. - Symptoms would typically include sudden onset of **pleuritic chest pain** and hypoxemia, which may or may not be present with shortness of breath.

Q: A 70-year-old man presents with fatigue, weight loss, and jaundice. Laboratory tests show elevated alkaline phosphatase and bilirubin levels. Imaging reveals bile duct dilation and a mass at the pancreatic head. A biopsy confirms adenocarcinoma. What is the likely diagnosis?

Pancreatic adenocarcinoma. ***Pancreatic adenocarcinoma*** - The presence of a **mass at the pancreatic head**, alongside elevated alkaline phosphatase and bilirubin levels, is indicative of pancreatic adenocarcinoma, often causing obstructive jaundice [1]. - **Fatigue** and **weight loss** are common systemic symptoms due to malignancy and are consistent with this diagnosis [2]. *Gallbladder carcinoma* - While it can present with jaundice, it more commonly involves **gallbladder-related symptoms** and typically does not manifest as a mass at the **pancreatic head**. - Imaging findings would show issues focused on the **gallbladder** or nearby structures rather than the **pancreatic duct**. *Hepatocellular carcinoma* - This type of cancer usually arises in the presence of **chronic liver disease** and may show liver lesions rather than a mass in the **pancreas**. - The imaging would likely demonstrate **focal liver lesions** rather than bile duct dilation associated with obstruction. *Cholangiocarcinoma* - Although it involves the bile ducts and can cause jaundice, it would typically present with a mass specifically in the **bile duct** rather than the **pancreatic head**. - Patients often showcase different imaging characteristics and potential intrahepatic lesions compared to the described findings [3].

Q: A 50-year-old woman with metastatic melanoma has started a new immunotherapy drug. Which of the following is a common side effect of immune checkpoint inhibitors?

Pneumonitis. ***Pneumonitis*** - **Pneumonitis** is a common and potentially severe immune-related adverse event (irAE) associated with immune checkpoint inhibitors, occurring when the activated immune system targets lung tissue. - Patients may present with cough, dyspnea, and hypoxia, and imaging often shows ground-glass opacities or interstitial infiltrates. *Nephrotoxicity* - While **renal irAEs** can occur, leading to **acute kidney injury** or interstitial nephritis, they are less common than pneumonitis or colitis. - The incidence of severe **nephrotoxicity** is relatively low compared to other organ toxicities. *Hepatotoxicity* - **Hepatotoxicity** in the form of **immune-mediated hepatitis** is a recognized irAE that can range from asymptomatic transaminitis to acute liver failure. - However, it occurs with a lower frequency than pneumonitis in many studies of immune checkpoint inhibitors. *Cardiotoxicity* - **Immune-mediated myocarditis** is a rare but life-threatening irAE, often presenting with non-specific symptoms like fatigue or dyspnea, or more severely as **heart failure** or arrhythmias. - Though highly morbid, its overall incidence is much lower than that of pneumonitis.

Q: What is the best tumor marker for pancreatic cancer?

CA 19-9. **CA 19-9** - **CA 19-9** is the most widely accepted and commonly used tumor marker for **pancreatic adenocarcinoma**, particularly for monitoring response to treatment and recurrence. - Elevated levels are often seen in patients with pancreatic cancer and can correlate with **tumor burden** and prognosis. *CA 15-3* - **CA 15-3** is primarily used as a tumor marker for **breast cancer**, not pancreatic cancer. - It is utilized for monitoring treatment response and detecting recurrence in patients with breast cancer, especially **metastatic disease**. *CEA* - **CEA (Carcinoembryonic Antigen)** is a general tumor marker elevated in various cancers, including **colorectal**, **lung**, and **gastric cancer**. - While it can be elevated in some pancreatic cancer cases, it is less specific and sensitive for pancreatic cancer than CA 19-9. *AFP* - **AFP (Alpha-fetoprotein)** is the primary tumor marker for **hepatocellular carcinoma (HCC)** and **germ cell tumors**. - It is not routinely used for the diagnosis or monitoring of pancreatic cancer.

Q: A 60-year-old female with chronic kidney disease presents with generalized weakness and hyperreflexia. Her serum calcium level is 14 mg/dL. What is the most likely cause?

Primary hyperparathyroidism. ***Primary hyperparathyroidism*** - In patients with **chronic kidney disease (CKD)**, the kidneys may struggle to activate Vitamin D, which can lead to **secondary hyperparathyroidism**. However, if hypercalcemia is present alongside hyperreflexia, this points to **primary disease**, where one or more parathyroid glands are overactive independently of serum calcium levels. - While CKD typically involves complications like **renal osteodystrophy** and **low calcium/high phosphate**, persistent hypercalcemia with hyperreflexia, especially at this critical level, despite CKD, strongly suggests autonomous **parathyroid gland dysfunction**. *Sarcoidosis* - Sarcoidosis causes **hypercalcemia** due to extrarenal production of **1,25-dihydroxyvitamin D** by activated macrophages. - While it can cause generalized weakness, hyperreflexia is not a typical neurological manifestation of sarcoidosis. *Thiazide diuretics* - Thiazide diuretics can cause mild **hypercalcemia** by increasing **renal calcium reabsorption**. - However, the serum calcium level of 14 mg/dL is usually more severe than what is typically caused by thiazide diuretics alone, and chronic kidney disease typically makes this less likely given impaired calcium and phosphate handling. *Malignancy-associated hypercalcemia* - **Malignancy-associated hypercalcemia** can present with severe hypercalcemia and generalized weakness, due to the release of **PTHrP** or bone destruction. - While possible, the combination of **chronic kidney disease** and hyperreflexia makes primary hyperparathyroidism a more specific and likely underlying cause in this scenario.

Q: A 65-year-old patient presents with hematuria, weight loss, and flank pain. CT shows a solid renal mass with calcifications and renal vein invasion. Laboratory results indicate hemoglobin of 10.8, ESR of 45, and creatinine of 1.6. What is the best diagnosis?

Renal cell carcinoma. ***Renal cell carcinoma*** - The classic triad of **hematuria, flank pain, and palpable mass** (though a palpable mass isn't explicitly stated, flank pain and hematuria are present) combined with **weight loss** and a **solid renal mass with calcifications and renal vein invasion** on CT are highly indicative of **renal cell carcinoma (RCC)** [1]. - The lab findings of **anemia (Hb 10.8)**, **elevated ESR (45)**, and mild renal dysfunction (creatinine 1.6) further support a diagnosis of RCC, especially with paraneoplastic syndromes. *Transitional cell carcinoma* - This typically arises in the **renal pelvis or ureter** and often presents with painless gross hematuria, but **solid mass with calcifications and renal vein invasion** is less characteristic of TCC. - While it can cause hematuria and flank pain, the imaging findings of a solid renal mass with calcifications and invasion are more typical of parenchymal tumors like RCC. *Angiomyolipoma* - This is a **benign tumor** composed of blood vessels, smooth muscle, and fat, making it appear hyperechoic or fat-containing on imaging, rather than a solid mass with calcifications. - It usually presents with symptoms only when large or hemorrhaging, and **weight loss and renal vein invasion** are not characteristic features. *Wilms' tumor* - Primarily affects **children**, typically presenting as an asymptomatic abdominal mass, hematuria, and hypertension. - This patient's age (65-year-old) makes Wilms' tumor an **extremely unlikely diagnosis** [1].

Q: A 55-year-old woman with cirrhosis is found to have a liver lesion with elevated alpha-fetoprotein. What is the most likely diagnosis?

Hepatocellular carcinoma. ***Hepatocellular carcinoma*** - **Elevated alpha-fetoprotein (AFP)** levels in a patient with cirrhosis are strongly indicative of hepatocellular carcinoma, which commonly arises in this context [1]. - Hepatocellular carcinoma typically presents as a **liver lesion** and is associated with chronic liver disease and cirrhosis [1]. *Hemangioma* - Generally, hemangiomas are **benign vascular tumors** and do not cause elevated levels of alpha-fetoprotein. - They are often asymptomatic and discovered incidentally on imaging, unlike hepatocellular carcinoma, which will present more aggressively in this setting. *Liver metastasis* - Liver metastases can occur in cirrhotic patients but are less likely to be associated with significant elevations of alpha-fetoprotein unless specific primary tumors are involved. - Primary tumors, such as colorectal cancer, usually produce **different markers**, and the presence of AFP suggests a primary liver cancer rather than metastatic disease. *Hepatic adenoma* - Hepatic adenomas are also benign tumors but are less common in patients with cirrhosis and typically do not cause elevated alpha-fetoprotein levels. - More frequently found in women taking **oral contraceptives**, they generally lack the aggressive features seen in hepatocellular carcinoma.

Q: A patient with non-small cell lung cancer (NSCLC) who is resistant to first-line chemotherapy should have which molecular marker evaluated to guide second-line targeted therapy?

EGFR mutation. ### EGFR mutation - **EGFR mutations** are common in NSCLC and can lead to resistance to first-line chemotherapy, specifically **tyrosine kinase inhibitors (TKIs)** [1]. - Identifying specific EGFR mutations, such as **T790M**, can guide the use of second-generation or third-generation EGFR TKIs like **osimertinib** as second-line therapy. *BRCA1 mutation* - **BRCA1 mutations** are primarily associated with an increased risk of **breast and ovarian cancers**, and occasionally prostate and pancreatic cancers. - They are not routinely evaluated or considered a primary target for guiding second-line therapy in NSCLC. *BCR-ABL fusion gene* - The **BCR-ABL fusion gene** is a hallmark of **chronic myeloid leukemia (CML)** and some cases of acute lymphoblastic leukemia (ALL) [1]. - This gene is a target for **tyrosine kinase inhibitors** like imatinib in these hematological malignancies but is not relevant for NSCLC [1]. *HER2 overexpression* - **HER2 overexpression** or amplification is a significant prognostic and predictive marker in **breast cancer** and some gastric cancers, guiding **trastuzumab** therapy [1]. - While HER2 alterations can occur in a small subset of NSCLC, they are less common and less established as a primary driver for second-line targeted therapy compared to EGFR mutations.

Question 1

A 55-year-old man presents with fatigue and splenomegaly. His complete blood count reveals a marked increase in mature lymphocytes. What condition is consistent with these findings?

Accepted Answer

Chronic lymphocytic leukemia

Answer

Acute myeloid leukemia

Answer

Chronic myeloid leukemia

Answer

Acute lymphoblastic leukemia

Question 2

A patient with known breast cancer presents with shortness of breath. A chest CT reveals multiple nodules throughout both lungs. What is the most likely diagnosis?

Accepted Answer

Metastatic disease

Answer

Primary lung cancer

Answer

Pneumonia

Answer

Pulmonary embolism

Question 3

Which of the following is the most appropriate screening test for colorectal cancer in average-risk individuals?

Accepted Answer

Comprehensive endoscopic examination of the colon (Colonoscopy)

Answer

Stool-based test for hidden blood (FOBT)

Answer

Imaging-based colon examination (CT colonography)

Answer

Endoscopic examination of the lower colon (Flexible sigmoidoscopy)

Question 4

A 70-year-old man presents with fatigue, weight loss, and jaundice. Laboratory tests show elevated alkaline phosphatase and bilirubin levels. Imaging reveals bile duct dilation and a mass at the pancreatic head. A biopsy confirms adenocarcinoma. What is the likely diagnosis?

Accepted Answer

Pancreatic adenocarcinoma

Answer

Cholangiocarcinoma

Answer

Hepatocellular carcinoma

Answer

Gallbladder carcinoma

Question 5

A 50-year-old woman with metastatic melanoma has started a new immunotherapy drug. Which of the following is a common side effect of immune checkpoint inhibitors?

Accepted Answer

Pneumonitis

Answer

Nephrotoxicity

Answer

Hepatotoxicity

Answer

Cardiotoxicity

Question 6

What is the best tumor marker for pancreatic cancer?

Accepted Answer

CA 19-9

Answer

CA 15-3

Answer

CEA

Answer

AFP

Question 7

A 60-year-old female with chronic kidney disease presents with generalized weakness and hyperreflexia. Her serum calcium level is 14 mg/dL. What is the most likely cause?

Accepted Answer

Primary hyperparathyroidism

Answer

Sarcoidosis

Answer

Thiazide diuretics

Answer

Malignancy-associated hypercalcemia

Question 8

A 65-year-old patient presents with hematuria, weight loss, and flank pain. CT shows a solid renal mass with calcifications and renal vein invasion. Laboratory results indicate hemoglobin of 10.8, ESR of 45, and creatinine of 1.6. What is the best diagnosis?

Accepted Answer

Renal cell carcinoma

Answer

Transitional cell carcinoma

Answer

Angiomyolipoma

Answer

Wilms' tumor

Question 9

A 55-year-old woman with cirrhosis is found to have a liver lesion with elevated alpha-fetoprotein. What is the most likely diagnosis?

Accepted Answer

Hepatocellular carcinoma

Answer

Hepatic adenoma

Answer

Liver metastasis

Answer

Hemangioma

Question 10

A patient with non-small cell lung cancer (NSCLC) who is resistant to first-line chemotherapy should have which molecular marker evaluated to guide second-line targeted therapy?

Accepted Answer

EGFR mutation

Answer

BRCA1 mutation

Answer

BCR-ABL fusion gene

Answer

HER2 overexpression

Oncology — MCQs

Oncology — MCQs

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