Question 1

A 44-year-old woman notes a lump in her left breast while taking a shower. Her physician notes a 3 cm
firm, irregular, non-movable mass located in the upper outer quadrant of her left breast on physical
examination. A fine needle aspiration of this mass is performed. Cells obtained from the mass are
examined cytologically and are consistent with infiltrating ductal carcinoma. The mass is removed with
lumpectomy along with an axillary lymph node dissection.

Which of the following findings will best predict a better prognosis for this patient?

A The tumor cells are strongly estrogen receptor positive

B No metastases are found in the sampled lymph nodes

C Flow cytometric analysis demonstrates aneuploidy and a high S-phase

D She has one relative who had a similar type of breast cancer

E The tumor has a high grade

[HIDE]
(B) CORRECT. The lack of metastases suggests a lower stage and a better prognosis.
[/HIDE]

Question 2
A change in bowel habits prompts a 53-year-old woman to see her physician. On physical examination
there are no lesions noted on digital rectal examination, but her stool is positive for occult blood. A
colonoscopy is performed and reveals a 6 cm friable mass located in the cecum. A biopsy of this mass is
performed and microscopic examination shows a moderately differentiated adenocarcinoma.

Which of the following findings is most likely to be present in this patient?

A A k-ras mutation in the neoplastic cells

B An immunoperoxidase stain positive for vimentin in the neoplastic cells

C A stool culture positive for Shigella flexneri

D A plasma HIV-1 RNA level of 40,000 copies/mL

E A high titer DNA topoisomerase I autoantibody

[HIDE]
(A) CORRECT. Many human carcinomas are associated with k-ras mutations that contribute to
oncogenesis.
[/HIDE]
Question 3
A 45-year-old healthy woman has a routine check of her health status. She has no chest pain, cough, or
fever. A chest x-ray taken and shows a peripheral 2.5 cm diameter "coin lesion" in the right mid-lung
field.

Which of the following biologic characteristics best distinguishes this lesion as a neoplasm,
rather than a granuloma?
A Recurrence following excision

B Rapid increase in size

C Sensitivity to radiation or chemotherapy

D Uncontrolled (autonomous) growth

E Necrosis

[HIDE]
(D) CORRECT. A neoplasm is new, uncontrolled growth of cells.
[/HIDE]

Question 3

A clinical study is performed on biopsy specimens obtained from patients who had a malignant neoplasm.
It is observed that a subset of these biopsies shows a neoplasm composed predominantly of cells with a
spindle shape and a high N/C ratio with marked pleomorphism. These cells are vimentin positive,
cytokeratin negative, and CD45 negative by immunohistochemical staining.

This type of neoplasm is most likely to have been diagnosed in which of the following patients?

A A 35-year-old woman with a left breast mass and enlarged axillary lymph nodes

B A 55-year-old woman with massive ascites and multiple peritoneal metastases

C A 25-year-old man with an enlarged left testis

D A 15-year-old man with a mass in the left femur and lung metastases

E A 5-year-old man with a right renal mass

[HIDE]
(D) CORRECT. He probably has an osteosarcoma with hematogenous metastases to lung.
[/HIDE]
Question 5

A 48-year-old woman goes to her physician for a routine physical examination. A 4 cm diameter non-
tender mass is palpated in her right breast. The mass appears fixed to the chest wall. Another 2 cm non-
tender mass is palpable in the left axilla. A chest radiograph reveals multiple 0.5 to 2 cm nodules in both
lungs.

Which of the following classifications best indicates the stage of her disease?

A T1 N1 M0

B T1 N0 M1

C T2 N1 M0

D T3 N0 M0

E T4 N1 M1

[HIDE](E) CORRECT. She has a large invasive primary tumor mass with axillary node and
lung metastases..[/HIDE]

Question 6
A study is performed to analyze characteristics of malignant neoplasms in biopsy specimens. The biopsies
were performed on patients who had palpable mass lesions on digital rectal examination.

Of the following microscopic findings, which is most likely to indicate that the neoplasm is
malignant?

A Pleomorphism

B Atypia

C Invasion

D Increased nuclear/cytoplasmic ratio

E Necrosis
[HIDE](C) CORRECT. Metastasis would be an even better indicator, but invasion suggests
malignancy more than the other items listed here.[/HIDE]
Question 7

Review of a series of surgical pathology reports indicates that a certain type of neoplasm is graded as
grade I on a scale of I to IV. Clinically, some of the patients with this neoplasm are found to be stage I.

Which of the following is the best interpretation of a neoplasm with this stage I
designation?

A Is unlikely to be malignant

B Has probably arisen from epithelium

C May spread via lymphatics

D Has an in situ component

E Is well-differentiated and localized

[HIDE](E) CORRECT. A well-differentiated and localized neoplasm usually has both a low grade and
stage.
[/HIDE]

Question 8
A 51-year-old man has worked for 10 years in a factory producing plastic pipe. He has noted weight loss,
nausea, and vomiting worsening over the past 5 months. On examination he is afebrile. There is
generalized muscle wasting. Laboratory studies show the serum alkaline phosphatase is 405 U/L with AST
67 U/L, ALT 55 U/L, and total bilirubin 1.2 mg/dL. An abdominal CT scan reveals a 12 cm right liver lobe
mass. Liver biopsy reveals a neoplasm composed of spindle cells forming irregular vascular channels. The
cells demonstrate vimentin positivity and cytokeratin negativity with immunohistochemical staining.

Exposure to which of the following substances most likely led to development of this
neoplasm?

A Benzene

B Radon

C Cyclophosphamide

D Asbestos

E Vinyl chloride

[HIDE](E) CORRECT. This is a rare cause of cancer. However, this causal relationship was
easy to demonstrate, because hepatic angiosarcoma is a rare neoplasm.[/HIDE]

Question 9
 A child is born with a single functional allele of a tumor suppressor gene. At the age of five the remaining
normal allele is lost through a point mutation. As a result, the ability to continue the transition from G1 to
the S phase of cell cycle is lost.

Which of the following neoplasms is most likely to arise via this mechanism?

A Infiltrating ductal carcinoma of breast

B Small cell anaplastic carcinoma of the lung

C Retinoblastoma of eye

D Cerebral astrocytoma

E Chronic myeloid leukemia

[HIDE](C) CORRECT. The Rb gene is the classic example of the 'two hit' mechanism for loss
of tumor suppression. About 60% of these tumors are sporadic, while others are familial,
and there is inheritance of a mutated copy of the Rb gene. Loss of the second copy in
retinoblasts leads to the occurrence of retinoblastoma in childhood.[/HIDE]

Question 10
A 22-year-old woman goes to her physician for a routine examination. A palpable nodule is found in the
right lobe of her thyroid gland. No lymphadenopathy is noted. A chest x-ray shows no masses. A fine
needle aspirate of the nodule is performed and cytologic examination reveals cells present consistent with
a papillary carcinoma of the thyroid. There are no other family members affected by this disorder. She
works as a secretary for an accounting firm part time and is earning a college degree.

Which of the following findings would you consider most relevant in her past history to
indicate a risk factor for this neoplasm?

A Chronic alcoholism

B Radiation therapy in childhood

C Ataxia telangiectasia

D Blunt trauma from a fall

E Exposure to arsenic compounds

[HIDE](B) CORRECT. Radiation is oncogenic. Cancers of thyroid and bone often develop in
children with radiation exposure. Leukemias can occur as well.[/HIDE]

1. Question 11

A 50-year-old man has felt vague abdominal discomfort for the past 4 months. On physical
examination he has no lymphadenopathy, and no abdominal masses or organomegaly can
be palpated. Bowel sounds are present. An abdominal CT scan shows a 20 cm
retroperitoneal soft tissue mass obscuring the left psoas muscle. A stool specimen tested for
occult blood is negative.

Which of the following neoplasms is this man most likely to have?

A Melanoma

B Hamartoma

C Adenocarcinoma

D Lymphoma

E Liposarcoma

[HIDE](E) CORRECT. Sarcomas are big and bad. Retroperitoneum is a typical

location.[/HIDE]

Question 12

A 52-year-old man has had increasing fatigue for the past 6 months. On physical
examination he has a palpable spleen tip. Laboratory studies show a WBC count of
189,000/microliter. The peripheral blood smear shows many mature and immature myeloid
cells present. Cytogenetic analysis of cells obtained via bone marrow aspiration reveals a
t(9:22) translocation. This translocation leads to formation of a hybrid gene that greatly
increases tyrosine kinase activity.

Which of the following genes is most likely translocated to cause these findings?

A p53

B Rb

C c-abl

D NF-1

E k-ras

[HIDE](C) CORRECT. This is the 'Philadelphia chromosome' of chronic myelogenous

leukemia.[/HIDE]

Question 13

A clinical study is performed of oncogenesis in human neoplasms. It is observed that some

neoplasms appear to develop from viral oncogenesis, with serologic confirmation of past
viral infection.

Which of the following neoplasms is most likely to arise in this manner?

A Retinoblastoma

B Small cell anaplastic carcinoma of lung

C T-cell leukemia

D Prostatic adenocarcinoma

E Hepatic angiosarcoma

[HIDE](C) CORRECT. Human T-lymphocytotropic virus (HTLV) infection can lead to T-cell
leukemia.[/HIDE]

Question 14

A 40-year-old woman has had a feeling of abdominal discomfort for the past 8 months. On
pelvic examination, there is a right adnexal mass. An abdominal CT scan demonstrates a 7
cm cystic mass involving the right ovary with small areas of calcification. The uterus is
normal in size. The right fallopian tube and ovary are removed surgically. Grossly, the mass
on sectioning is filled with abundant hair and sebum. Microscopically, the mass has
glandular spaces lined by columnar epithelium, squamous epithelium with hair follicles,
cartilage, and dense connective tissue.

Which of the following statements regarding this type of neoplasm is most appropriate?

A A sarcomatous element is usually present.

B A human papillomavirus infection preceded development of this mass.

C Metastases are unlikely to be present.

D Primitive immature tissues resembling those from an embryo can usually be seen.

E Such a mass is often seen to arise in the testis.

[HIDE](C) CORRECT. The cystic nature and circumscribed appearance of the mass are
consistent with a mature cystic teratoma, which contains tissues representing all germ
layers of the embryo.[/HIDE]

Question 15

A 29-year-old woman with a history of multiple sexual partners over the last 15 years has a
routine physical examination with no abnormal findings. On pelvic examination, the cervix
shows no abnormalities, but a Pap smear is taken and dysplastic cells are reported to be
present. A cervical biopsy is performed and shows microscopic features of a minimal
dysplasia (CIN 1) involving the cervical squamous epithelium.

Which of the following is the most appropriate statement to make to the patient regarding
these findings?

A No further treatment is indicated

B Antibiotic therapy will be necessary

C You probably have widespread metastases

D Complete excision of the lesion is required

E You have inherited a BRCA-1 mutation

[HIDE](D) CORRECT. Cervical dysplasia is a pre-neoplastic condition that has the potential
to develop into a carcinoma if not treated.[/HIDE]

Question 16

A 64-year-old man has noted a 5 kg weight loss along with increasing fatigue over the past
year. He has experienced dull abdominal pain for the past week. He has developed
abdominal distention with lack of stools in the past two days. On physical examination,
bowel sounds are reduced. An abdominal CT scan reveals a mass involving the descending
colon. At laparotomy, a partial resection of the left colon is performed, with removal of an
encircling mass in the descending colon. Microscopically, the mass is found to be a
moderately differentiated adenocarcinoma.

Which of the following laboratory test findings is most likely to be present in this man?

A Microcytic hypochromic anemia

B Positive antinuclear antibody test

C Hyperglycemia

D Elevated alpha-fetoprotein

E Decreased lactate dehydrogenase

[HIDE](A) CORRECT. He has an adenocarcinoma of the colon. Such lesions are often
associated with blood loss from mucosal erosion and necrosis.[/HIDE]

Question 17

A 14-year-old healthy girl has a 0.3 cm reddish, slightly raised nodule on the skin of the
upper part of her chest found on a routine physical examination. She states that this lesion
has been present for years and has not appreciably changed in size or color.

Which of the following neoplasms is this nodule most likely to be?

A Hemangioma

B Melanoma

C Wilms tumor

D Lymphoma

E Glioma

[HIDE](A) CORRECT. Hemangiomas, teratomas, and fibromatoses are common pediatric

neoplasms which are benign.[/HIDE]

Question 18

A 56-year-old man has had a chronic cough for the past year. He is a non-smoker. He had
an episode of hemoptysis 3 days ago. No abnormal findings are noted on physical
examination. A chest x-ray demonstrates a 6 cm perihilar mass. A sputum sample is
collected, and the sputum cytology report reads "Atypical cells present suggestive of
squamous cell carcinoma."

Which of the following environmental exposures is most likely to be associated with these
findings?

A Asbestos

B Radon

C Silica

D Benzene

E Formaldehyde

[HIDE](B) CORRECT. Radon gas is considered to be the second most common cause for
lung cancer following tobacco smoking. However, most persons with radon exposure who
develop lung cancer are also smokers.
[/HIDE]

Question 19

A 60-year-old man who has a 90 pack year history of cigarette smoking has had a chronic
cough for the past 10 years. He has begun to lose weight (3 kg) during the past year. No
abnormal findings are noted on physical examination. He has a chest radiograph that
reveals a right hilar mass. A sputum cytology shows atypical, hyperchromatic squamous
 cells.

What is the most common initial pathway of spread of this lesion?

A Bloodstream

B Pleural cavity

C Contiguous spread to chest wall

D Lymphatics

E Bronchi

[HIDE](D) CORRECT. Epithelial malignancies such as a squamous cell carcinoma of the lung
often spread initially to regional lymph nodes.[/HIDE]

Question 20

A 55-year-old man dies after a year-long illness. At autopsy the liver contains multiple
tumor masses from 2 to 5 cm in size that are mostly firm and tan and that grossly exhibit
umbilication with central necrosis.

Which of the following statements would best characterize the significance of such an
appearance?

A There is multicentric origin of a benign neoplasm.

B The neoplasm has a high grade.

C The primary neoplasm is in the stomach.

D A carcinogen was the underlying cause for the neoplasm.

E The neoplasm has an advanced stage.

[HIDE](E) CORRECT. The most likely possibility is that these masses represent metastases.
Thus, the neoplasm has an advanced stage.[/HIDE]
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2. 03-14-2009, 04:16 PM#3

trimurtulu

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Question 21

A 59-year-old man has had a worsening cough with chest pain for the past 6 months. On
physical examination he has no remarkable findings. A chest x-ray shows a 3 cm left lung
mass. A sputum cytology specimen yields cells diagnosed as a squamous cell carcinoma. A
mediastinoscopy is performed and reveals metastases in a lymph node. He is given
radiation therapy, and the mass diminishes in size.

Which of the following cellular mechanisms is most likely to account for this tumor
response?

A Point mutations in DNA of irradiated cells

B Generation of free radicals in irradiated cells

C Loss of the blood supply to the neoplastic cells

D Secondary inflammation in the neoplasm

E Adenosine triphosphate depletion in the irradiated cells

[HIDE](B) CORRECT. The purpose of therapeutic radiotherapy is to try and kill more
neoplastic cells than normal cells. This is mediated mainly through generation of oxidant
free radicals.[/HIDE]

Question 22

A 60-year-old woman has a firm mass with irregular borders felt in her left breast on a
routine physical examination. A fine needle aspiration is performed and microscopic
examination shows an infiltrating ductal carcinoma. A left mastectomy with axillary lymph
node dissection is performed. A tissue sample of this neoplasm is submitted for analysis by
flow cytometry.

Which of the following does flow cytometric analysis most likely provide?

A Determination of the karyotype

B Diagnosis of benign neoplasms

C Determination of aneuploidy

D Distinguishing carcinoma from sarcoma

E Quantitation of RNA content

[HIDE](C) CORRECT. Flow cytometry can detect the degree of aneuploidy from the DNA
content. Aneuploidy implies that the neoplasm is worse than if it were not
aneuploid.[/HIDE]

Question 23

A 35-year-old woman had a firm nodule palpable on the dome of the uterus six years ago
recorded on routine physical examination. The nodule has slowly increased in size and now
appears to be about twice the size it was when first discovered. She remains
asymptomatic.

Which of the following neoplasms is she most likely to have?

A Adenocarcinoma

B Leiomyosarcoma

C Hematoma

D Leiomyoma

E Metastasis

[HIDE](D) CORRECT. The slow growth of the nodule and the lack of symptoms suggests a
benign course. Leiomyomas of the uterus are quite common (20% of women).[/HIDE]

Question 24

A 15-year-old boy has had lumps in the right neck for the past 5 months. On physical
examination there is painless lymphadenopathy in the right cervical region. One of the
lymph nodes is biopsied and on microscopic examination shows many lymphocytes that are
large, with clumped chromatin and occasional mitoses.

The characterization of this population of lymphocytes as a neoplasm is best accomplished

by which of the following methods?

A Immunohistochemical staining identifying leukocyte common antigen

B Gene rearrangement studies that demonstrate clonality

C Flow cytometry indicating a high S-phase

D A differential white blood count showing a lymphocytosis

E Demonstrating fibrosis within the mass by light microscopy

[HIDE](B) CORRECT. Clonality is a key characteristic of neoplastic cellular proliferations that

distinguishes them from reactive proliferations (such as inflammation).[/HIDE]

Question 25

A previously healthy 42-year-old man has a skin nodule on his right hand that has become
larger and darker with more irregular outlines over the past three months. On physical
examination there is a 1.2 cm diameter darkly pigmented and slightly raised nodule on the
dorsum of his right hand. No other skin lesions are noted. Several nontender enlarged
lymph nodes are palpable in the right axilla. The lesion is excised and microscopic
examination shows a neoplasm composed of darkly pigmented polygonal and spindle cells.

Which of the following risk factors is most important for development of this neoplasm?

A Cigarette smoking

B Allergy to latex gloves

C Inheritance of a faulty Rb gene

D Prior job-related asbestos exposure

E Chronic exposure to ultraviolet radiation

[HIDE](E) CORRECT. Worldwide, more and more skin cancers, including melanoma, are
occurring because of sun exposure. The UV light damages the skin and damages cellular
DNA, leading to mutations that escape cellular repair mechanisms.
[/HIDE]

Question 26

A a 27-year-old woman in excellent health has a routine health maintenance examination. A

2 cm firm, rounded mass is palpable beneath the skin of the left forearm. She has no
difficulty using the arm and there is no associated pain with the mass, either in movement
or on palpation. The overlying skin appears normal. The mass does not change in size over
the next year.

Which of the following neoplasms is she most likely to have?

A Metastatic carcinoma

B Melanoma

C Rhabdomyosarcoma

D Lipoma

E Leiomyoma

[HIDE](D) CORRECT. The small size of the lesion, the relatively young age of the patient,
and the lack of other findings suggests a benign process.[/HIDE]
Question 27

A 41-year-old woman has noted a foul-smelling vaginal discharge for 3 weeks. On physical
examination there is an exophytic 3 cm mass involving the ectocervix. Pap smear testing is
performed; she has never had a previous Pap smear. Cytologic changes are present on this
Pap smear that are consistent with squamous cell carcinoma. She is found to have a
positive serologic test for syphilis. Her serum glucose is 157 mg/dL. She has been a
commercial sex worker in the past.

Which of the following is the most likely risk factor for her cervical carcinoma?

A Human papillomavirus infection

B Diabetes mellitus, type II

C Heavy cigarette smoking

D Pelvic inflammatory disease

E Previous cancer chemotherapy

[HIDE](A) CORRECT. HPV infection, a sexually transmitted disease (STD), is highly

associated with cervical dysplasias and malignancies. Syphilis is not a risk for epithelial
dysplasias or carcinomas, but if one STD is present, others can be present as well.[/HIDE]

Question 28

A 60-year-old man with an 80 pack year history of smoking experiences an episode of

hemoptysis. On physical examination he has puffiness of the face, some pedal edema,
bruises of the skin, and a blood pressure of 165/100 mm Hg. A chest radiograph reveals a 5
cm right upper lobe lung mass. A fine needle aspirate of this mass yields cells consistent
with small cell anaplastic ("oat cell") carcinoma. A bone scan shows no metastases.

Immunohistochemical staining of the tumor cells is likely to be positive for which of the
following hormones?

A Parathormone related peptide

B Erythropoietin

C ACTH

D Insulin

E Gastrin

[HIDE](C) CORRECT. He has Cushing syndrome from ectopic ACTH production by the
tumor, a form of paraneoplastic syndrome common to 'oat cell' carcinomas of the
lung.[/HIDE]

Question 29

A 45-year-old woman has noted a lump on her left shoulder that has enlarged over the past
4 months. On physical examination there is an enlarged, non-tender supraclavicular lymph
node. A biopsy of the node is done and on microscopic examination there is a metastatic
neoplasm.

Which of the following is the most likely primary neoplasm?

A Cerebral glioma

B Adenocarcinoma of the colon

C Fibroadenoma of the breast

D Liposarcoma of the retroperitoneum

E Laryngeal papilloma

[HIDE](B) CORRECT. Lymph node metastases are typical of carcinomas.

[/HIDE]

Question 30
A 59-year-old man went to his physician for a routine health maintenance examination. The
only abnormal physical examination finding is a positive stool guaiac test. Laboratory
studies show a CBC with Hgb 10.0 g/dL, Hct 29.8&, MCV 73 fL, platelet count
300,000/microliter, and WBC count 8700/microliter. He is found on colonoscopy to have a 4
cm mass lesion arising on the mucosal surface of the transverse colon.

Which of the following statements is most appropriate regarding these findings?

A This is an uncommon site for a primary malignant neoplasm

B Microscopically, the mass is probably an adenocarcinoma

C Persons who are smokers are at much greater risk to develop this lesion

D Hypercalcemia is a frequent paraneoplastic complication

E The predicted 5 year survival rate is less than 5%

[HIDE](B) CORRECT. The glandular epithelial surface of the colon gives rise to
adenocarcinomas.[/HIDE]

Question 31

Columnar epithelial cells from the colonic mucosa are studied to identify abnormalities in
cell signaling pathways. Abnormal epithelial cells from colonic adenocarcinoma are shown to
have a mutation that blocks hydrolysis of GTP-bound active RAS. Normal columnar cells
have active RAS protein that undergoes hydrolysis to the inactive GDP-bound form.

Which of the following signaling pathways is most likely abnormally stimulated in the
carcinoma cells?

A ADP

B BCR-ABL

C Cyclic AMP

D Cyclin D1

E MAP kinase

F p53

[HIDE](E) CORRECT. The mechanism described is that of RAS oncogene activation in which
the active RAS is permanently turned on and through the MAP kinase pathway activates
transcription that drives cellular proliferation that leads to neoplasia.[/HIDE]

Question 32

A 52-year-old woman feels a lump in her right breast and goes to her physician. On physical
examination there is a 3 cm right breast mass fixed to the chest. This mass is biopsied and
on microscopic examination shows nests of cells with marked hyperchromatism and
pleomorphism. These cells are estrogen receptor positive. Flow cytometry is performed.

Compared with surrounding non-neoplastic stromal cells, the neoplastic cells are more likely
to be in which of the following phases of the cell cycle?

A G0

B G1

CS

D G2

EM

[HIDE](C) CORRECT. A high S-phase, as well as aneuploidy, are features often seen in
cancers. The hyperchromatism indicates active DNA synthesis. The estrogen receptor
positivity suggests that this breast cancer will respond to hormonal therapy with
tamoxifen.[/HIDE]
Question 33

A 70-year-old healthy man is found to have a palpable firm nodule in the prostate gland on
digital rectal examination. His serum prostate specific antigen (PSA) is 19 ng/mL. The
microscopic appearance seen on biopsy of the prostate will probably be most consistent with
which of the following conditions?

A Chronic prostatitis

B Adenocarcinoma

C Infarction

D Leiomyoma

E Rhabdomyosarcoma

[HIDE](B) CORRECT. The nodule and the elevated PSA together strongly suggest
neoplasia. [/HIDE]

Question 34

In an experiment, it is observed that chronic, increased exposure to ionizing radiation

results in damage to cellular DNA. As a consequence, a protein is now absent that would
arrest the cell in the G1 phase of the cell cycle. Subsequent to this, the cell is transformed
to acquire the property of unregulated growth.

The absent protein is most likely the product of which of the following genes?

A k-ras

B p53

C c-myc

D c-abl

E Bcl-2

[HIDE](B) CORRECT. Abnormal p53 has been identified in many carcinomas. This loss of
normal tumor suppression leads to development of carcinomas.[/HIDE]

Question 35
A 50-year-old woman notes a lump in her left breast. She goes to her physician's assistant,
who palpates a 2 cm firm mass in her left breast. A fine needle aspiration biopsy is
performed, and on microscopic examination a ductal carcinoma is seen.

A poorer prognosis for the patient is most closely associated with which of the following
findings?

A Aneuploidy by flow cytometry

B Positive immunohistochemical staining for estrogen receptor

C A well-differentiated histologic appearance

D Intraductal growth pattern

E Stage of T1 N0 M0

[HIDE](A) CORRECT. Aneuploidy is bad because such neoplastic cells tend to be much less
differentiated and much more aggressive.[/HIDE]

Question 36

An epidemiologic study is performed to determine risk factors for development of malignant

neoplasms. A statistical analysis of pre-existing medical conditions is done. Some pre-
existing conditions are observed to precede development of malignant neoplasms, while
others do not. Which of the following conditions is most likely to be statistically unrelated to
subsequent malignancy?

A Endometrial atypical hyperplasia

B Chronic alcoholism with hepatic cirrhosis

C Cervical squamous dysplasia

D Chronic ulcerative colitis

E Uterine leiomyomas

[HIDE](E) CORRECT. Many women have multiple uterine leiomyomas. Leiomyosarcomas of

the myometrium are rare and develop de novo.[/HIDE]

Question 37
A 35-year-old man has noted several 1 to 2 cm reddish purple, nodular lesions present on
the skin of his right arm which have increased in size and number over the past 3 months.
The lesions do not itch and are not painful. He has had a watery diarrhea for the past
month. On physical examination he has generalized lymphadenopathy and oral thrush.

Which of the following infections is most likely to be related to the appearance of these skin
lesions?

A Candida albicans

B Human herpesvirus 8

C Mycobacterium tuberculosis

D Pseudomonas aeruginosa

E Pneumocystis carinii (jiroveci)

[HIDE](B) CORRECT. These plaque-like reddish lesions are characteristic for Kaposi
sarcoma. HHV8 (KSHV) is the agent that promotes angiogenesis from which the KS arises in
persons with HIV infection.[/HIDE]

Question 38

A 66-year-old woman has developed a chronic cough over the past 2 months. No abnormal
physical examination findings are noted. A chest x-ray shows a 3 cm mass in the right
upper lobe. After fine needle aspiration biopsy, the mass is resected. Gross and microscopic
examination of the mass is performed and it is determined that a neoplasm is present.

Which of the following findings regarding this mass is most likely to be irrelevant for
determining further therapy and prognosis?

A Is the neoplasm invading the margin of resection?

B What is the size of the neoplasm?

C What is the degree of atypia and pleomorphism of the neoplastic cells?

D How much inflammation is present in the neoplasm?

E Is the neoplasm primary or metastatic?

[HIDE](D) CORRECT. Inflammation by itself does not have diagnostic or prognostic value in
neoplasia.[/HIDE]
Question 39

A 49-year-old man complains of pain in his left thigh for 3 months. On physical examination
his thigh is increased in size, compared to the right. A plain film radiograph reveals the
presence of a 15 cm solid mass that does not appear to arise from bone, but it does have
infiltrative margins. A biopsy of this mass is taken, and on microscopic examination the
mass is composed of highly pleomorphic spindle cells.

Which of the following immunohistochemical markers is most likely to be demonstrated in

the cells of this mass?

A Cytokeratin

B Factor VIII

C Alpha fetoprotein

D Lambda light chain

E Vimentin

[HIDE](E) CORRECT. The location and size and histologic characteristics suggest a sarcoma.
Vimentin is an intermediate filament often found in neoplasms of mesenchymal
origin.[/HIDE]

Question 40

A clinical study is performed with patients who had a diagnosis of breast cancer.
Characteristics of the grade, stage, molecular biology, and histologic type are analyzed. Of
the following characteristics, which is most likely to be associated with the best prognosis
for these patients?

A Increased expression of laminin receptors

B Increased cathepsin expression

C Decreased apoptosis

D Decreased doubling time

E Decreased nuclear/cytoplasmic ratio

[HIDE](E) CORRECT. An increased N/C ratio is a feature of malignancy, but a normal to

decreased N/C ratio is not a feature of malignancy.[/HIDE]

Question 41
A 66-year-old man has noted darker urine for the past 2 weeks. A urinalysis shows
hematuria. He is referred to a urologist who performs cystoscopy. A 3 cm mass is found in
the dome of the bladder. Biopsies of the mass are taken and on microscopic examination
show a urothelial carcinoma. Cells of this neoplasm demonstrate a single mutation causing
cellular inability to hydrolyze GTP, thus resulting in cellular transformation.

Which of the following oncogenes is most likely implicated in this case?

A c-abl

B c-neu

C c-sis

D k-ras

E n-myc

[HIDE](D) CORRECT. The ras gene can be turned on by a mutation to make it an

oncogene.[/HIDE]

Question 42

A 44-year-old woman who has had multiple sexual partners for the past 30 years has an
abnormal Pap smear with cytologic changes suggesting human papillomavirus infection.

Without treatment, she is most likely to develop which of the following lesions?

A Squamous cell carcinoma

B Non-Hodgkin's lymphoma

C Kaposi's sarcoma

D Adenocarcinoma

E Leiomyoma

[HIDE](A) CORRECT. HPV infection leads to dysplasias and squamous carcinomas in the
cervix. HPV is a sexually transmitted infection.[/HIDE]

Question 43

In an epidemiologic study, "fallout" from nuclear bomb testing and from nuclear power plant
disasters is observed to have released radioactive isotopes into the environment. One of
these isotopes is found to be strontium-90. It is observed that the strontium-90 in soils
goes into the food chain and eventually contaminates milk products.
This contamination is most likely to increase the risk for which of the following neoplasms?

A Kaposi sarcoma of skin

B Small cell anaplastic carcinoma of lung

C Osteosarcoma

D Nasopharyngeal carcinoma

E Endometrial carcinoma

[HIDE](C) CORRECT. The fallout includes Strontium-90, an isotope that can be taken up
into bone just like calcium, but promotes neoplastic transformation.[/HIDE]

Question 44

A clinical trial of a new chemotherapy protocol is performed involving patients with lung
carcinoma. It is observed that a response occurs that leads to DNA strand breakage and
carcinoma cell death. The primary carcinomas are initially observed to decrease in size
following therapy. However, after 3 months, the carcinoma is no longer regressing with this
therapy.

Altered expression of which of the following by the neoplastic cells has most likely resulted
in this reduced response?

A Vimentin

B Leukocyte common antigen

C Laminin receptor

D Actin

E DNA topoisomerase II

[HIDE](E) CORRECT. This is a nuclear enzyme which untangles DNA at the end of mitosis.
The drugs that target topoisomerase II freeze the enzyme as it is cutting DNA strands. This
leads to DNA strand breakage and cell death. Resistant cells in culture show alterations in
the topoisomerase II protein.[/HIDE]

Question 45
In an experiment, biologic characteristics of neoplastic and non-neoplastic cells are analyzed
in culture. It is observed that cell division in cells derived from malignant neoplasms, but
not in normal cells, is aided by the presence of an enzyme which repairs progressive
chromosomal shortening. The lack of chromosomal shortening allows the malignant cells to
undergo many more divisions than the normal cells.

Which of the following enzymes is most likely to have this effect?

A Reverse transcriptase

B DNA polymerase

C Telomerase

D Protein kinase

E Topoisomerase

[HIDE](C) CORRECT. The telomerase synthesizes telomeric chromosomal ends. The so-
called 'immortal' neoplastic cell lines may result from the presence of this enzyme.
Interfering with it may promise a new cancer therapy.[/HIDE]

Question 46

A 62-year-old man has complained of pain on urination for the past week. He is afebrile. On
cystoscopy, a slightly erythematous 1 cm diameter area is seen on the bladder mucosa.
This area is biopsied and on microscopic examination shows cells with marked
hyperchromatism and increased nuclear/cytoplasmic ratio involving the full thickness of the
epithelium. However, these changes are confined to the epithelium above the basement
membrane.

Which of the following terms best describes these biopsy findings?

A Metaplasia

B Minimal dysplasia

C Microinvasion

D Hyperplasia

E Carcinoma in situ

[HIDE](E) CORRECT. Malignancy confined to the epithelium is CIS, and such lesions when
excised have essentially a 100% cure rate.[/HIDE]
Question 47

A 32-year-old woman has noted dull pelvic pain for the last two months. On physical
examination there is a mass palpated in the right lower quadrant. An abdominal ultrasound
reveals an 8 cm mass involving the right ovary. The mass is surgically excised. On gross
inspection, the surface of the mass is smooth, is not adherent to surrounding pelvic
structure, and is cystic and filled with hair on sectioning. On microscopic examination there
is squamous epithelium, tall columnar glandular epithelium, cartilage, and fibrous
connective tissue.

Which of the following neoplasms is she most likely to have?

A Choristoma

B Hamartoma

C Myxoma

D Teratoma

E Mesothelioma

[HIDE](D) CORRECT. A teratoma is a neoplasm derived from totipotential germ cells that
differentiate into tissues that represent all three germ layersectoderm, endoderm, and
mesoderm. When the elements are all well differentiated, the neoplasm is 'mature'
(benign).[/HIDE]

Question 48

A 54-year-old woman had an episode of coughing with blood-streaked sputum. On physical

examination she appeared cachectic. A chest x-ray showed an irregular mass lesion in the
right lung. A transbronchial biopsy was done and on microscopic examination showed small
cell anaplastic carcinoma. She was treated with a multidrug chemotherapy regimen and had
a partial response. However, metastatic disease is now present eight months later. A second
chemotherapy protocol is tried, but no response is noted.

Which of the following is the most likely reason for failure of the second protocol to elicit a
response?

A The neoplastic cells have an abnormal p53 protein

B This carcinoma was caused by a viral infection

C A ras oncogene has been activated

D The neoplastic cells have increased P-glycoprotein

E There is a second primary lung cancer present

[HIDE](D) CORRECT. The increase in P-glycoprotein allows the cells to pump out any toxin,
including any chemotherapy agent.[/HIDE]

Question 49

A previously healthy 66-year-old man has been feeling tired for 5 months. He goes to his
physician, who performs a complete physical examination, including stool guaiac, which is
positive. A colonoscopy is performed, and a large, sessile 4.5 cm mass with surface
ulceration is found in the cecum. A biopsy of this mass microscopically shows irregular
glands with crowded, tall columnar cells having marked nuclear hyperchromatism.

Which of the following statements about his condition is most accurate?

A His relatives have hereditary adenomatous polyposis

B There is lack of apoptosis from a faulty Bcl-2 gene

C A p53 mutation is present in the neoplastic cells

D He has hereditary non-polyposis colon cancer

E He has inherited a faulty Rb gene from one parent

[HIDE](C) CORRECT. He has an adenocarcinoma of the colon. At his age, APC and HNPCC
are very unlikely. It takes many years for sporadic mutations to have occurred that
contribute to development of most malignancies.[/HIDE]

Question 50

An 8-year-old boy has complained of difficulty swallowing for the past month. On physical
examination he has a palpable, firm mass in the right neck. A head CT scan reveals a 7 cm
solid soft tissue mass lateral to the esophagus on the right. A biopsy of this mass
demonstrates pleomorphic spindle cells that are cytokeratin negative, CD45 negative, and
vimentin positive. Further history indicates that this boy was affected by fetal alcohol
syndrome and he does poorly in school.

Which of the following neoplasms is he most likely to have?

A Wilms tumor

B Rhabdomyosarcoma

C Neuroblastoma

D Ewing's sarcoma

E Malignant lymphoma

[HIDE](E) CORRECT. This is one of the more common childhood tumors of soft tissue.
Sarcomas tend to be vimentin positive, while carcinomas are cytokeratin positive and
lymphomas CD45 positive.[/HIDE]

Question 51

A 53-year-old woman feels a lump in her right breast. Her physician palpates an irregular 3
cm mass that is not movable because it appears fixed to the overlying skin, which is
retracted. A mastectomy is performed and the pathologist on sectioning the breast finds a 3
x 3.5 cm ovoid mass that does not have discrete borders, but appears to infiltrate into the
surrounding fibrofatty breast stroma. The mass is firm, white, and has a fibrous
consistency.

Which of the following features is most likely demonstrated by the gross appearance of this
mass?

A Anaplasia

B Aplasia

C Desmoplasia

D Dysplasia

E Metaplasia

[HIDE]
(C) CORRECT. Neoplasms, and malignant neoplasms in particular, can form a fibrous stroma
that gives the tumor a characteristic firm or hard feel on palpation. This connective tissue
can fix the tumor to surrounding structures. An infiltrating ductal carcinoma of the breast
will often have this appearance.[/HIDE]

Question 52

A 66-year-old man has a routine physical examination and a stool sample proves positive
for the presence of occult blood. He undergoes colonoscopy and a 5 cm sessile mass is
present in the sigmoid colon. Biopsy of the mass yields a diagnosis of adenocarcinoma. A
chest x-ray shows multiple 1 to 3 cm nodules in both lungs.

Presence of which of the following in the neoplastic cells is most likely to explain the
presence of lung nodules?

A Vimentin

B Leukocyte common antigen

C Laminin receptor

D Telomerase

E DNA topoisomerase II

[HIDE](C) CORRECT. Laminin receptors allow neoplastic cells to attach more readily to
basement membranes.
[/HIDE]

Question 53

A healthy 22-year-old woman undergoes a routine physical examination. A discrete, firm,

rubbery, movable mass is found in the left breast. She has no axillary lymphadenopathy.
The skin overlying the breast and the nipple appear normal.

Which of the following neoplasms is most likely to be present?

A Lipoma

B Intraductal carcinoma

C Malignant lymphoma

D Fibroadenoma

E Leiomyoma

[HIDE](D) CORRECT. The description is that of a benign neoplasm. Fibroadenoma is the

most common benign neoplasm of the breast.
[/HIDE]

Question 54

An epidemiologic study is performed involving patients with long-standing Epstein-Barr virus

infection. It is observed that these patients have an increased risk for development of
malignant neoplasms in adulthood.

Which of the following neoplasms is most likely to be found in these patients?

A Kaposi sarcoma

B Small cell anaplastic carcinoma of lung

C Osteosarcoma

D Nasopharyngeal carcinoma

E Endometrial carcinoma

[HIDE](D) CORRECT. EBV infection is most often linked to nasopharyngeal carcinoma and to
Burkitt's lymphoma.[/HIDE]

Question 55

A 45-year-old man has felt increasingly fatigued for the past 8 months. There are no
remarkable physical examination findings. Laboratory studies show a WBC count of
250,000/microliter. A bone marrow biopsy is performed that shows the marrow is 100%
cellular with an increase in both mature myeloid cells and their precursors. Cytogenetic
analysis of the marrow reveals cells with a 9:22 translocation.

Which of the following is most likely to be involved in this process?

A bcr

B c-neu

C c-sis

D k-ras

E n-myc

[HIDE](A) CORRECT. This is the 'Philadelphia chromosome' in which the oncogene abl is
spliced onto the bcr region of chromosome 22, resulting in increased tyrosine kinase
activity.[/HIDE]

Question 56

A 29-year-old woman feels a nodule in her neck. On examination there is a firm 2 cm mass
in the right lobe of her thyroid. A fine needle aspiration shows cells consistent with papillary
carcinoma. 2 years ago she had a lobular carcinoma excised from her left breast. Her 31-
year-old sister was recently diagnosed with endometrial carcinoma. Over 3 generations, 16
of 24 close relatives have had a malignancy, most diagnosed before age 35.

Which of the following most likely explains the increased risk for cancer in these people?

A Autosomal dominant cancer syndrome

B Defective DNA repair syndrome

C Germline mosaicism

D Multifactorial inheritance

E Teratogen

F Viral infection

[HIDE](D) CORRECT. Cancer that runs in families often does not have a clearly defined
pattern of inheritance and does not have a specific genetic marker. Familial cancers should
be suspected when cancers occur at a younger age, multiple family members are involved,
and multiple sites are involved. The sites of involvement (breast, colon, thyroid, kidney,
ovary) are similar to those for sporadic cancers.[/HIDE]

Question 57

A study of malignant neoplasms reveals that some of them have a greater potential for
invasion and metastases. Analysis of the cells of cancers that have metastasized reveals a
mutation which results in decreased cell surface expression of E-cadherin.

Which of the following genes is most likely mutated to produce these findings?

A beta-catenin

B BRCA-2

C Cyclin D

D NF-1

E RAS

F Rb

G RET
[HIDE](A) CORRECT. Beta-catenin binds to the intracellular portion of cadherins, which
anchor cells together, and the loss of this function results in less cell adhesiveness that
favors tumor cell infiltration and metastases. Beta-catenin also binds to a nuclear
transcription factor that increases cell proliferation, and loss of normal beta-catenin function
leads to cell proliferation.[/HIDE]

Question 58

An experiment is conducted in which proliferating cells are subjected to ionizing radiation.

The ionizing radiation leads to arrest in a checkpoint that monitors completion of DNA
replication. It is observed that there are increased numbers of chromosomal abnormalities
in these cells. Which of the following is the checkpoint affected by the ionizing radiation?

A G0/G1

B G1/S

C S/G2

D G2/M

E M/G0

[HIDE](D) CORRECT. This is the second checkpoint in the cell cycle; ionizing radiation
activates this checkpoint, resulting in chromosomal abnormalities in mitosis.[/HIDE]