Practice Test 2answers can be found on page 17

1. A 52-year-old woman with stage III melanoma is receiv-ing high-dose interferon therapy. She has completed thefour weeks of daily intravenous therapy and is now in thefifth month of maintenance subcutaneous therapy withinterferon. Laboratory analyses performed on the previousday demonstrated a normal complete blood count anddifferential count, but the serum bilirubin was 1.9 mg/dL,the asparate aminotransferase was 420 U/L, and thealanine aminotransferase was 380 U/L. The patient feelswell at this time except for fatigue. A physical examinationperformed last week was normal.

Which of the following treatment options would yourecommend?

A. Continue with the current treatment planB. Discontinue interferon therapy permanentlyC. Continue interferon, but reduce the dose by 50%D. Discontinue interferon and start treatment with IL-2

(aldesleukin)E. Discontinue interferon until the liver function tests normal-

ize, then restart interferon at a 50% dose reduction

2. A 38-year-old premenopausal woman is referred fortreatment of metastatic breast cancer. She was diag-nosed 18 months earlier with a T1, N0, M0, poorly dif-ferentiated invasive ductal cancer that was ER negative,PR negative, and HER2 positive (3+ staining). The pri-mary tumor was 0.6 centimeters in the largest diameter.She was treated with a total mastectomy and axillarydissection; of 16 lymph nodes removed, all were nega-tive for disease. No adjuvant systemic therapy wasrecommended.

The current evaluation now demonstrates bilateral,asymptomatic pulmonary metastases, a small left pleuraleffusion, and multiple areas of increased uptake on bonescan, involving the ribs, spine, and pelvis. X-rays of thebone are remarkably unimpressive, showing one five-cen-timeter lytic lesion in the right ileum. Cytologic analysis ofpleural fluid is positive for adenocarcinoma cells, consis-tent with the earlier diagnosis of breast cancer.

In addition to intravenous bisphosphonate therapy,which of the following would you recommend?

A. Classical CMFB. Weekly intravenous trastuzumab aloneC. Paclitaxel combined with trastuzumab

D. AC combined with trastuzumab E. AC alone

3. A 34-year-old woman with CML in chronic phase hasreceived an allogeneic bone marrow transplant withoutdepletion of the T cells. The transplant donor is an HLA-identical brother. The preparative regimen included busul-fan and cyclophosphamide. At one year after thetransplant, disease is in morphologic and cytogenetic com-plete remission, but a PCR assay performed for the firsttime is positive for BCR-ABL.

Which of the following statements best describes thesignificance of the positive assay?

A. It has no significanceB. It increases the risk of relapse to 40%, compared with 4%

if the assay were negativeC. It increases the risk of relapse to 80%, compared with 4%

if the assay were negativeD. It represents an early indication of inevitable relapse

4. A 55-year-old man presents because of multiple lungand liver metastases found on routine follow-up CT twoyears after treatment for stage III cancer of the sigmoidcolon. He was treated with resection and postoperativeadjuvant chemotherapy with fluorouracil and leucovorin.Examination of a biopsy sample of the liver lesiondemonstrates adenocarcinoma consistent with aprimary cancer of the colon. The results of laboratorytests are as follows: total bilirubin, 2.1 mg/dL; creatinine,0.8 mg/dL; alkaline phosphatase, 108 U/L; aspartateaminotransferase, 22 U/L; alanine aminotransferase, 12U/L; and albumin, 4.0 g/dL. He is eager to begin treat-ment and understands that no treatment offers curativepotential.

Which of the following would you recommend?

A. Irinotecan, fluorouracil, and leucovorin as a bolus adminis-tration

B. Irinotecan, fluorouracil, and leucovorin as an infusionC. Capecitabine as single-agent therapyD. Oxaliplatin, fluorouracil, and leucovorinE. No therapy because the patient is asymptomatic and

chemotherapy offers no survival benefit

5. Which of the following histologic subtypes of Hodgkins lym-phoma is most likely to respond to treatment with rituximab?

Practice Test 2 | 1

A. Nodular sclerosingB. Nodular lymphocyte-predominantC. Mixed cellularityD. Lymphocyte depletedE. None of the above

6. A 60-year-old woman at high risk of breast cancerbecause of an extensive family history and a personalhistory of lobular carcinoma in situ asks what heroptions are for decreasing her risk of breast cancer risk.

Which of the following measures has been demon-strated in clinical trials to decrease the five-year risk ofbreast cancer for this woman?

A. Tamoxifen therapyB. Raloxifene therapyC. Annual mammographyD. Adoption of a low-fat diet

7. A 72-year-old man presents with symptomatic bonemetastases secondary to prostate cancer. The baselinehemoglobin was 11 g/dL and the PSA level at the startof hormone treatment was 250 ng/mL. Androgen abla-tion was initiated with a three-month depot of goserelin,a gonadotropin-releasing hormone analogue, and theantiandrogen bicalutamide. After six months of therapy,the symptoms improved, and the level of PSA was unde-tectable. He continued to be monitored every threemonths. At month 18, the PSA level was 10 ng/mL, withno change in other parameters. A repeat PSA level was15 ng/mL. A testosterone level is at castrate level.Bisphosphonate therapy was initiated recently.

Which of the following should be the next intervention?

A. ChemotherapyB. Ketoconazole and hydrocortisoneC. Change to a different bisphosphonateD. Discontinue bicalutamide but continue therapy with goserelinE. Strontium-89 or samarium-153

8. A 62-year-old man presents for routine outpatient fol-low-up eight months after completing initial treatmentwith concurrent cisplatin-based chemoradiotherapy forT3, N2b, M0 squamous cell cancer of the right tonsil.He was rendered free of disease. He has had mild dys-phagia and odynophagia for approximately three weeks.He is otherwise asymptomatic and reports having nofever, chills, nausea, vomiting, weight loss, cough,hemoptysis, or trismus. He continues to work full-time.

On physical examination, a recurrent ulcerated mass isclearly noted in the area of the right tonsil, with exten-

sion into the soft palate; it is clinically T3 in extent.Evaluation of the neck reveals changes as a result ofradiation but no clear evidence of recurrent disease. Theremainder of the physical examination is unremarkable.

The results of a complete blood count, serum chemistrytests, and liver function tests are within normal limits. CTof the neck confirms the recurrent tonsillar mass. Achest x-ray and other diagnostic evaluations show noevidence of distant metastases. Analysis of a biopsyspecimen from the tonsillar mass demonstrates a poorlydifferentiated squamous cell cancer. Consultation with aradiation oncologist indicates that the recurrence issquarely within the prior radiation field.

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

A. Single-agent chemotherapyB. Combination chemotherapyC. Salvage-combined chemoradiotherapy with intensity-modu-

lated radiotherapyD. Referral to a head and neck surgeon

9. IFN-2 has been demonstrated to have clinically sig-nificant single-agent antitumor activity against which oneof the following malignant diseases?

A. Chronic myelogenous leukemiaB. Acute myelogenous leukemiaC. Metastatic colorectal cancerD. Acute lymphocytic leukemia (non-T cell)E. Small cell bronchogenic cancer

10. A 59-year-old man is referred for evaluation of per-sistent lymphocytosis. On physical examination, he isfound to have cervical, axillary, and inguinal lym-phadenopathy. The white blood cell count is 19,000/L.Your differential diagnosis includes CLL.

Which of the following tests is most likely to yield thediagnosis?

A. Lymph node biopsyB. Bone marrow biopsyC. Examination of the peripheral bloodD. Immunophenotyping of peripheral blood lymphocytes

11. Which one of the following statements mostaccurately describes trends in the incidence of breastcancer?

A. The incidence of breast cancer is decreasing in industrial-ized countries. It is estimated that 150,000 new cases willbe diagnosed worldwide in 2004, and a similar number inthe United States

2 | Practice Test 2

B. The incidence of breast cancer is higher in developingcountries than in the industrialized world. More than twomillion cases will be diagnosed worldwide in 2004,300,000 of them in the United States

C. The incidence of breast cancer has been increasing gradu-ally for the past 25 years. It is estimated that in 2004,breast cancer will develop in 217,440 women in theUnited States and in 1,300 men

D. In western industrialized countries, breast cancer is thethird most common cancer among women, accounting for900,000 cases in the United States and Western Europe

E. Lung cancer has displaced breast cancer as the mostcommon cancer among women in the United States; sincethe introduction of screening mammography, fewer than100,000 new cases of breast cancer are diagnosed yearlyin the United States

12. A 26-year-old woman presents for a second opinionregarding the management of melanoma. Five years ago,she was treated for a malignant melanoma on the lowerpart of the abdomen. The melanoma was 0.9 millimeterthick, there was no ulceration, and the Clark level was III.She was treated with wide excision that showed no resid-ual melanoma and was then monitored. She now has anenlarged right inguinal lymph node that measures 2.5centimeters by 2.0 centimeters. The lymph node isremoved and is positive for melanoma. A staging work-up,including CT of the chest, abdomen, and pelvis, is nega-tive for metastatic disease.

Which of following treatment options would you nowrecommend to this patient?

A. Isolated limb perfusionB. Complete inguinal lymph node dissectionC. High-dose interferon therapyD. No further therapyE. Radiation therapy to the inguinal lymph node basin

13. A 62-year-old woman will begin treatment formetastatic colon cancer. She is strongly in favor ofreceiving capecitabine in combination with oxaliplatin.Currently, she is taking a beta blocker for hypertension,warfarin for atrial fibrillation, and estrogen for post-menopausal symptoms.

Which of the following is appropriate?

A. Use capecitabine at full doses but change the beta blockerto an angiotensin converting enzyme (ACE) inhibitor

B. Reduce the capecitabine dose to avoid an interaction withthe warfarin

C. Stop the estrogen-replacement therapy, as it is contraindi-cated for patients with colon cancer

D. Maintain full doses of capecitabine and closely monitor thecoagulation parameters

E. Reduce the oxaliplatin dose because full doses are knownto worsen the renal function of patients with preexistinghypertension

14. A radiograph of the right humerus of an 18-year-oldwoman with pain just distal to the shoulder shows a scle-orotic humeral lesion with evidence of destruction of thecortex and a surrounding soft tissue component (Fig. 1).CT of the chest showed no evidence of metastatic disease.

Standard treatment for the most common primary sar-coma evident on the radiograph includes which of thefollowing?

A. Surgery onlyB. Surgery and radiation therapyC. Surgery and chemotherapyD. Surgery, radiation therapy, and chemotherapy

15. A 62-year-old man presents with a one-month his-tory of cough. Over the last week, he has had severalepisodes of hemoptysis. On review of symptoms, he alsoreports that he has had increasing fatigue, decreasedappetite, and a loss of five to 10 pounds. He has noother meaningful medical history and has otherwisebeen well. He smokes approximately two packs of ciga-rettes daily.

3

Figure 1.

Practice Test 2 |

On physical examination, he appears well developedand well nourished, and the ECOG performance statusof 1. No focal physical findings are noted. A chest x-raydemonstrates a large right hilar mass. CT of the chestconfirms the hilar mass, a large, bulky, right-sided medi-astinal adenopathy, and no other pulmonary, adrenal, orliver lesions. The findings on bone scan and on CT of thehead made with contrast medium are negative. Theresults of percutaneous needle biopsy are positive forsmall cell cancer.

Which of the following is most likely to yield long-termsurvival?

A. Cisplatin and etoposide followed by radiation therapy to thethorax at 60 Gy administered in daily fractions over six weeks

B. Cisplatin and etoposide plus concurrent radiation therapyto the thorax at 45 Gy administered in daily fractions overfive weeks

C. Cisplatin and etoposide followed by radiation therapy to thethorax at 45 Gy administered twice daily over three weeks

D. Cisplatin and etoposide plus concurrent radiation therapy tothe thorax at 45 Gy administered twice daily over threeweeks

E. Cisplatin and etoposide, with radiation therapy at 45 Gyadministered on relapse of disease

16. The patient described in question 15 has a completeresponse to combined-modality treatment. You decide todiscuss prophylactic cranial radiation with him.

In addition to reducing brain recurrence, which of thefollowing statements is true regarding the use of radia-tion therapy in this setting?

A. Prophylactic cranial radiation decreases the morbidityassociated with brain metastases but at the price of adecrease in cognitive function and with no improvement insurvival

B. Prophylactic cranial radiation decreases the morbidityassociated with brain metastases without any significantimpact on cognitive function and no improvement in sur-vival

C. Prophylactic cranial radiation decreases the morbidityassociated with brain metastases and improves survival butwith increased long-term cognitive defects

D. Prophylactic cranial radiation decreases the morbidityassociated with brain metastases and improves survival,with minimal long-term cognitive defects

17. A 45-year-old woman is found to have a locallyadvanced cervical cancer that is treated with externalbeam radiation therapy along with weekly cisplatin (40mg/m2). At the completion of radiation therapy, the

patients condition appears to be improved but shehas persistent disease, which is confirmed by CT. Twomonths after the completion of chemoradiotherapy,the patient reports having back pain that prevents herfrom sleeping. She also notes a major decrease inappetite and a loss of 15 pounds over the past month.A repeat CT scan demonstrates a number of newlyenlarged retroperitoneal lymph nodes (three to fourcentimeters in diameter), a growing pelvic mass (fourcentimeters by five centimeters), and several pul-monary nodules (one to three centimeters), whichwere not present on the previous CT scan.

Which of the following would you recommend?

A. Surgery to remove the pelvic mass and enlarged nodes,followed by chemotherapy with cisplatin and paclitaxel

B. Chemotherapy with cisplatin and ifosfamideC. Pelvic exenteration followed by surgical removal of the

pulmonary nodulesD. Palliative measures to treat symptoms and provide comfortE. Whole abdomen radiation therapy followed by cisplatin-

based chemotherapy

18. In addition to a history and physical examination,which of the following procedures should be includedfor the optimal surveillance of patients with primarybreast cancer after local, regional, and systemic thera-pies have been completed?

A. History and physical examination every four to six monthsduring the first five years and yearly thereafter. Annualmammography of the remaining breast tissue

B. History and physical examination, complete blood count,and liver function tests every four to six months during thefirst five years and yearly thereafter. Annual mammographyof the remaining breast tissue

C. History and physical examination, complete blood count,liver function tests, and tumor markers every four to sixmonths during the first five years and yearly thereafter.Annual mammography of the remaining breast tissue

D. History and physical examination, complete blood count,liver function tests, tumor markers, bone scan, and abdom-inal imaging every four to six months during the first fiveyears and yearly thereafter. Annual mammography of theremaining breast tissue

E. Whole-body PET every four to six months during the firstfive years, then yearly thereafter

19. Which cytogenetic abnormality and resulting proteinare associated with the lymphoma associated with thehighest likelihood of cure?

4 | Practice Test 2

A. t(11;14) and cyclin D1B. t(14;18) and BCL-2C. t(2;5) and ALKD. t(9;14) and PAX-5E. t(1;14) and CARD

20. A 75-year-old man with chronic heart failure anddementia had a left hemicolectomy for colon cancer.The proximal and distal margins of resection are free oftumor within more than four centimeters. Metastasis isidentified in three of 10 lymph nodes. The patient is fullyambulatory, lives with his wife of 40 years, and is takingthe following medications: simvastatin and hydrochlor-thiazide. You are consulted regarding the need for addi-tional therapy.

Which of the following do you recommend?

A. No additional therapyB. Six cycles of adjuvant therapy with fluorouracil and leucov-

orinC. Six cycles of adjuvant therapy with irinotecan, fluorouracil,

and leucovorinD. Radiation therapy to the primary tumor site and regional

lymph nodesE. Six cycles of fluorouracil/leucovorin and oxaliplatin

21. A 55-year-old woman with breast cancer that ismetastastic to the bone presents because of substantialpain that is not well controlled with a nonsteroidal anti-inflammatory drug. Her physician decides to begin treat-ment with a narcotic. The patient is educated withregard to the side effects of narcotic medications and istold that many of the side effects are temporary but thattolerance generally does not develop to one side effect,making it a chronic toxicity that may need to be chroni-cally managed with other medications.

Which of the following side effects is this chronic toxic-ity that oftentimes needs ongoing management?

A. NauseaB. SedationC. ConstipationD. Cognitive impairment

22. A 52-year-old man presents with a cough of severalweeks duration but without any other symptoms. He isable to perform normal activities. A mediastinal mass isidentified on routine chest x-ray, and right supraclavicu-lar node, two centimeters by three centimeters, is foundon physical examination. Results from biopsy of the nodeestablishes the diagnosis of diffuse large B-cell non-

Hodgkins lymphoma. Additional staging includes nega-tive findings on bone marrow biopsy. CT shows multipletwo to three-centimeter retroperitoneal nodes. PETscanning does not identify any other sites of disease.Laboratory evaluation includes normal levels of liverenzymes except for an LDH of 350 U/L. The plan is totreat him with CHOP chemotherapy.

Which of the following are the likelihood of completeresponse and the five-year disease-free survival?

A. 87% and 73%B. 67% and 51%C. 55% and 43%D. 44% and 26%

23. A 61-year-old woman is noted to have bilateralaxillary and inguinal adenopathy with no hepatos-plenomegaly during a routine physical examinationdemonstrates. She says that she has not had fevers,chills, or sweats. The results of a complete blood countinclude a white blood cell count of 21,000/L, with 79%apparently mature lymphocytes, and a hematocrit of35%. The platelet count is 86,000/L. A repeat plateletcount two weeks later is 59,000/L. Immunopheno-typing confirms the tentative diagnosis of CLL. Furtherstaging includes a bone marrow aspiration and biopsy,the results of which indicate diffuse bone marrow infil-tration by 60% lymphocytes, with normal numbers oferythroid precursors and megakaryocytes.

Which of the following statements is correct?

A. She has stage I disease and requires no therapyB. She has stage I disease and requires treatment with corti-

costeroidsC. She has stage I disease and requires treatment with flu-

darabineD. She has stage IV disease and requires treatment with

fludarabineE. She has stage IV disease and requires treatment with

corticosteroids

24. Clustering of multiple cases of breast and othercancers has been observed in some families.

Which of the following statements best describes theassociation of genetic abnormalities with specific famil-ial breast cancer syndrome?

A. RB translocation is associated with Cowdens syndromeB. BRCA2 mutations are associated with Li-Fraumeni syn-

dromeC. AKT mutations are associated with familial estrogen-excess

syndrome

5Practice Test 2 |

D. TP53 mutation is associated with Li-Fraumeni syndromeE. Estrogen receptor gene is hypermethylated and inactive in

tumors with BRCA2 mutations

25. A 53-year-old woman has testing of bone mineraldensity as part of a general health evaluation. She has ahistory of breast cancer that was appropriately treated inthe past. She has no evidence of residual or recurrentdisease and her prognosis is good. The results of bonemineral density testing demonstrate a T score of -1.0,which is an indication of mild osteopenia but not osteo-porosis. The patient has no family history of osteoporo-sis. Her diet does not include many dairy products.

Which of the following should you recommend for thispatient?

A. Calcium and vitamin DB. CalcitoninC. A bisphosphonateD. Vitamin E

26. A 47-year-old woman presents for a screening mam-mogram. Her mother, who is Jewish, had breast cancer atage 36. A maternal aunt had breast cancer at age 40. Thewoman has two preteen daughters. She has no siblings. Amammogram detects a 0.8-centimeter suspicious abnor-mality in the lateral portion of the right breast. The patientand her mother become very anxious, and before anyadditional diagnostic work-up they request genetic testing.

Who should be tested?

A. WomanB. MotherC. AuntD. Elder daughterE. Younger daughter

27. With regard to the patient described in question 26,which of the following techniques should be used for thegenetic testing?

A. Southern blottingB. Comparative genomic hybridizationC. cDNA microarray analysisD. KaryotypingE. Taqman assay

28. Initial testing is carried out for the patient describedin question 26, and the results are negative. The familywishes to have a more thorough genetic evaluation.They are willing to pay the expenses themselves.

Which of the following tests should be done next?

A Nucleotide sequencingB. Comparative genomic hybridizationC. cDNA microarray analysisD. KaryotypingE. Taqman assay

29. With regard to the patient described in question 26,needle-localization procedure is carried out on the massthat appeared as an abnormality on mammography, andevaluation of the specimen indicates ductal cancer thatis HER2 negative. Lumpectomy is done, and evaluationof the mass demonstrates that it is an intraductal cancerwith clean margins and a single area of microinvasion.The sentinel nodes are negative for disease. The patientis well educated and wants the most up-to-date molec-ular testing done to assist in determining the prognosisand need for chemotherapy.

Which of the following tests should be carried out on thespecimen obtained at lumpectomy?

A. Comparative genomic hybridizationB. Determination of ER and PR status and S-phase fraction

and ploidy analysisC. cDNA microarray analysisD. Protein truncation assayE. Karyotyping

30. With regard to the patient described in question 26,the genetic analysis of the mother is delayed because oftechnical problems. However, the aunt has determinedthat she carries a BRCA2 mutation. The patient is anx-ious and wants advice about minimizing her long-termrisk of breast cancer risk.

Which of the following would you recommend?

A. Daily aspirinB. Prophylactic bilateral mastectomyC. OophorectomyD. B and CE. None of the above

31. A 40-year-old woman presents with hematuria. A CTscan shows an eight-centimeter mass in the left kidney.The findings of physical examination are negative, and acomplete blood count and screening profile are within nor-mal limits. A CT scan of the chest shows four lesions on theright lung, each approximately 1.5 centimeter in diameter,which were not evident on chest x-ray two years earlier.Evaluation of a biopsy specimen indicates renal cell cancer.

Which of the following would your managementapproach not include?

6 | Practice Test 2

A. Resection of the renal mass followed by administration ofIFN-

B. Resection of all disease followed by administration of high-dose IL-2

C. ObservationD. Treatment wih low-dose IL-2E. Resection of the pulmonary lesions followed by resection

of the primary tumor

32. Which of the following is the most favorable cytoge-netic finding in patients with CLL?

A. Normal cytogenetic characteristics B. Trisomy 12C. 11q-D. 13q-

33. Clinical trials with taxanes in the adjuvant setting thathave been reported to date have led to several conclusions.

Which of the following statements is the most accuratewith respect to taxanes?

A. Paclitaxel is more effective than docetaxel in the adjuvantsetting

B. Docetaxel is more effective than paclitaxel in the adjuvantsetting

C. The addition of a taxane to an established anthracycline-containing chemotherapy regimen improves disease-freeand overall survival rates

D. Taxanes reduce the need for breast reconstructionE. Docetaxel followed by paclitaxel represents the most

effective utilization of taxanes in the adjuvant setting

34. A 47-year-old woman presents two year after com-pleting therapy for high-risk stage II breast cancer.Treatment included lumpectomy, radiation therapy, andadjuvant chemotherapy with cyclophosphamide anddoxorubicin. She now has new-onset anemia and throm-bocytopenia and is found to have AML with inv(16).

Which of the following statements is true?

A. Because of the timing of the leukemia, it is highly unlikelythat it is associated with the previous therapy

B. Because of the cytogenetic characteristics of the leukemia,it is highly unlikely that it is associated with the previoustherapy

C. The leukemia may be associated with the previous therapyand, therefore, although inv(16) is usually associated witha high rate of complete response, that is not the case forthis patient

D. The leukemia may be associated with the previous therapy,but given the inv(16), a high rate of complete response canbe expected

35. Which of the following describes some of the differ-ences between atypical carcinoid and small cell lungcancer?

A. Small cell lung cancer cells have a greater number ofneuroendocrine granules as detected by electronmicroscopy

B. Small cell lung cancer cells have a greater number ofmitoses found by light microscopy

C. Atypical carcinoids found in the lung are likely to repre-sent metastases from the gastrointestinal tract, whereassmall cell lung cancer is almost always primary to the lung

D. Atypical carcinoids are more likely to be associated withsmoking

36. Fourteen days ago, a 40-year-old man with acutelymphocytic leukemia in second relapse received aninfusion of G-CSF-mobilized peripheral blood stem cellsfrom a matched unrelated donor following a condition-ing regimen of cyclophosphamide and total-bodyradiation. He is now being evaluated for the recent onsetof jaundice.

On physical examination, scleral icterus is noted. A milderythematous rash is also observed on the upper part ofthe back, and the patient reports that it has been pres-ent for two days. The liver is palpable two fingerbreadthsbelow the right costal margin and is tender to palpation.There is a suggestion of ascites. He is febrile (38.2C),and he had a weight gain of approximately nine poundsover the past week. After a nadir peripheral white bloodcell count following transplantation, the count has recov-ered to 0.7 103/L and the platelet count is40,000/L. The results of liver function tests havebecome increasingly abnormal, with a serum bilirubin of6 mg/dL, a serum aspartate aminotransferase of 160U/L, and a serum alanine aminotransferase of 420 U/L.

Which of the following is the most likely cause of thepatients clinical condition?

A. Allogeneic engraftment syndromeB. Graft-versus-host diseaseC. Biliary sludge associated with hyperalimentationD. Veno-occlusive disease of the liverE. Cyclosporine toxicity

37. Which of the following describes the cancer mortal-ity rate of a country?

A. Percentage of patients with cancer in a country who diefrom cancer each year

B. Absolute number of patients with cancer in a country whodie of cancer in a given year

Practice Test 2 | 7

C. Number of people who die of cancer per 100,000 individu-als living in the country in a given year

D. Number of people diagnosed with potentially fatal cancersper 100,000 cases per year

38. A 62-year-old woman who has had pelvic discomfortfor several months is found to have an enlarged leftovary. The CA-125 antigen level is 97 U/mL. The patientis referred to a gynecologic oncologist who performs alaparotomy with a definitive resection of the mass.Pathologic review indicates a stage I (grade 3) epithelialovarian cancer.

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

A. CT of the abdomen and pelvis every eight weeks for threeyears

B. Six courses of a platinum (cisplatin or carboplatin)-basedchemotherapy

C. Physical examination and measurement of the CA-125antigen level every three months for two years, then everysix months for three years then yearly

D. Repeat exploration by laparotomy or laparoscopy in oneyear

E. Whole abdomen radiotherapy followed by four cycles ofplatinum-based chemotherapy

39. A 68-year-old woman is referred to you for addi-tional treatment four weeks after surgical resection for atumor in the ascending colon that was determined onpathologic evaluation to be a moderately differentiatedadenocarcinoma of the colon arising from a villousadenoma. The tumor had penetrated through theserosa, and three of 12 lymph nodes were positive formetastatic cancer. No other disease was seen at thetime of surgery.

Preoperatively, the CEA level was 1.2 ng/mL, and CT ofthe chest, abdomen, and pelvis demonstrated nometastasis.

She has recovered from surgery well except for a slowrecovery of normal bowel function, with two to threestools a day, compared with one stool per day preoper-atively. Her history includes diabetes controlled with oralagents, hypertension poorly controlled with a beta-blocker and a diuretic, and a hysterectomy for fibroids.She lives with her husband, is active, and is able to driveand maintain her own household.

Which of the following would you recommend?

A. 12 months of treatment with fluorouracil and leucovorinB. Six months of treatment with fluorouracil, leucovorin, and

levamisole

C. Six months of treatment with fluorouracil, leucovorin, andirinotecan

D. Six months of treatment with fluorouracil and leucovorinE. No treatment

40. A 67-year-old woman presents for a bimonthlyevaluation, and recurrence of lymphedema and axil-lary adenopathy is noted. The woman was first seenone year ago for a left supraclavicular and axillaryadenopathy that was asymptomatic. At that time, a fol-licular lymphoma was identified at that site only. Shewas observed with no therapy for six months, at whichtime chemotherapy with CHOP was initiated becausethe size of the axillary nodes had increased, causingmild lymphedema. After six cycles of treatment, nodisease was evident on computerized tomography.She returned three months later with recurrence ofedema; on restaging, new mediastinal adenopathywas found, in addition to recurrence in the axillary andsupraclavicular nodes. The findings of repeat biopsyconfirmed follicular lymphoma. Treatment with ritux-imab was started and was complicated by mild wheez-ing and fever on the first day of infusion. After twomonthly cycles of rituximab, complete regression wasconfirmed and treatment was discontinued.

At the present time, nine months after treatment wasdiscontinued, the lymphocyte count is 900/mm3 and thecomplete blood count and chemistry panel are other-wise unremarkable.

When considering treatment options, which of thefollowing should influence your thinking regardingrituximab?

A. It is likely she will have neutralizing antibodies to ritux-imab that will negate its therapeutic activity

B. Because of her history of wheezing on the first day ofinfusion of the drug, there is a strong possibility of anaphy-laxis during re-treatment

C. Response rates associated with rituximab as re-treatmentare essentially equivalent to those for patients who havehad a previous response

D. Aletuzemab is a noncross-reactive antibody to CD20 andshould be given

E. A cytokine-release syndrome can be expected to developon re-treatment

41. A 70-year-old man presents with a three-week historyof increasing weakness of the left arm and leg. The med-ical history indicates no evidence of prior malignant dis-ease, recent infection, or use of immunosuppression. Onphysical examination, he has reduced strength in the left

8 | Practice Test 2

arm and leg, but there is no adenopathy or other abnor-mal findings.

Magnetic resonance imaging (MRI) shows a solitaryuniformly contrast-enhanced mass lesion in the rightposterior frontal lobe (Fig. 2). Tumor specimen obtainedby biopsy indicates large B-cell lymphoma. The com-plete blood count; serum chemistries levels, includingliver enzymes and LDH; and HIV serology are normal, asare the findings on slit lamp eye examination. Theresults of CT of the chest, abdomen, and pelvis are nor-mal. The results of MRI of the spine are unremarkable,and no malignant cells are found on cytologic analysis ofcerebrospinal fluid.

Which of the following is the best treatment option?

A. Whole-brain radiation therapyB. Excision of the mass lesionC. Chemotherapy with cyclophosphamide, doxorubicin, vin-

cristine, and prednisone (CHOP)D. High-dose methotrexate-based chemotherapyE. Concurrent methotrexate-based chemotherapy and whole-

brain radiation therapy

42. A 39-year-old patient with a history of hemophilia Apresents with a three-week history of an enlarging glandon the left side of the neck. Infection with HIV was diag-nosed five years earlier and treated initially with zidovu-dine (AZT) and then with combination therapycontaining a nucleoside analogue (D4T) and an HIV pro-tease inhibitor. The CD4 count increased after the initi-

ation of multiagent HIV therapy, but decreased to lessthan 100/L over the past three years.

Physical examination demonstrates a left cervicalmass (six by eight centimeters). The findings on CTand a gallium scan show disease confined to the leftside of the neck. Evaluation of bone marrow and abiopsy specimen shows involvement with lymphoma.The morphologic and phenotypic studies of thetissue from the neck mass confirm the diagnosis oflymphoma.

What is the likely histologic type of lymphoma in thisclinical setting?

A. T-cell large lymphomaB. Large B-cell lymphomaC. Non-T cell, non-B-cell lymphomaD. Natural killer cell lymphoma

43. Referring to the patient described in question 42,which of the following statements is true about what thediagnostic lymphoid tissue will carry?

A. HHV-8, with 100% probabilityB. EBV, with 100% probabilityC. EBV, with less than 50% probabilityD. Human papillomavirus with 100% probability

44. A 53-year-old premenopausal woman is found tohave a small palpable mass in the upper, inner quadrantof the left breast. On physical examination, the mass isestimated to be 1.2 centimeters in largest diameter. Noregional lymph nodes were palpable. Bilateral mam-mography confirms the presence of a stellate mass inthe upper, outer quadrant of the left breast. There arealso diffuse calcifications throughout the upper, innerquadrant of the left breast and in two separate areas ofthe right breast.

The results of stereotactic biopsy of the original abnor-mality on the left side indicate an area of infiltrating duc-tal cancer with DCIS. The invasive tumor is ER positive,PR positive, and HER2 negative. The findings of biopsyof the two additional abnormalities of the left breastdemonstrate mixed ductal and lobular carcinoma insitu. A biopsy specimen is obtained from the rightbreast, and the results indicate that the abnormalities onmammography were benign.

Which of the following is the preferred treatment optionfor this patient?

A. Lumpectomy, axillary dissection, radiation therapy, fourcycles of AC, and trastuzumab for one year

Practice Test 2 |

Figure 2.

9

B. Total left mastectomy with immediate breast reconstruc-tion, sentinel lymph node biopsy, four cycles of AC, andtamoxifen for five years

C. Bilateral simple mastectomy with left sentinel node biopsyand anastrozole for five years

D. Lumpectomy, bilateral breast radiation therapy, and tamox-ifen for five years

E. Radiofrequency ablation of all three abnormal areas ofthe breast, axillary dissection, radiation therapy, andtamoxifen for five years followed by letrozole for fiveyears

45. A 32-year-old man presents with a four-week historyof a cough and an enlarging testicular mass. The evalu-ation shows five pulmonary nodules in the left lung; thelargest is 1.5 centimeters. A CT scan of the abdomenshows multiple enlarged nodes in the retroperitoneum(maximum size, 10 centimeters). Laboratory valuesinclude a lactate dehydrogenase level of 800 U/L, analpha-fetoprotein level of 3,500 units and an HCG levelof 4 mIU/mL. The testicular mass is removed and thepathologic diagnosis is embryonal cancer with elementsof choriocarcinoma and teratoma is made. He receivesthree cycles of cisplatin, etoposide, and bleomycin, withresolution of symptoms and normalization of markers.Imaging studies after the three cycles of chemotherapyshow no evidence of disease in the chest, but theabdominal examination reveals a three-centimeterresidual mass in the retroperitoneum.

Which of the following would you recommend?

A. FDG-PET and observation to ensure that there is no residualdisease

B. Change in therapy to vinblastine, ifosfamide, and cisplatinC. Two additional cycles of cisplatin, etoposide, and

bleomycinD. Surgical exploration of the abdomen, with dissection of

retroperitoneal lymph nodesE. Radiation therapy to the abdomen

46. Which of the following is true regarding screening forlung cancer?

A. In randomized screening studies conducted during the1980s, chest x-rays with or without cytologic analysis ofsputum failed to detect earlier stage cancers in screenedgroups

B. Low-dose, thin-slice spiral CT, without the use of contrastmedium, is more sensitive than chest x-rays for the detec-tion of lung nodules and lung cancer at early stages

C. Although screening with low-dose, thin-slice spiral CT,

without the use of contrast medium, has an impact on themortality related to lung cancer, the technique is not cost-effective for lung cancer screening

D. Low-dose, thin-slice spiral CT, without the use of contrastmedium, is more effective than chest x-rays at differentiat-ing cancers from granulomatous disease

47. Which of the following is true regarding neoadjuvant(preoperative) chemotherapy for stage I, II, and III dis-ease?

A. Neoadjuvant chemotherapy has improved survival in large,randomized phase III trials

B. The primary role of neoadjuvant chemotherapy is to renderunresectable disease resectable

C. Neoadjuvant chemotherapy does not affect postoperativemortality

D. Survival is better for patients who have pathologically stagedN2 nodes downstaged to N0 following neoadjuvant chemother-apy than for patients whose nodes were not downstaged

48. Clinical trials have demonstrated that the risk ofbreast cancer can be reduced by several medical inter-ventions.

Which of the following statements is false?

A. Prophylactic bilateral mastectomy is associated with amarked reduction in the risk of breast cancer

B. Prophylactic bilateral ovarian ablation before age 45 isassociated with a substantial reduction in risk, even forwomen with familial breast cancer

C. For postmenopausal women, hormone-replacement therapyusing a combination of estrogens and progestins substan-tially reduces the risk of breast cancer

D. Tamoxifen administered for five years is associated with a30% to 50% reduction in risk

E. Selective aromatase inhibitors are associated with consid-erable reductions in the incidence of second primarybreast cancers

49. A 59-year-old man is diagnosed with CLL. Because ofdisease-related symptoms and a rapidly increasing lym-phocyte count, therapy is initiated with fludarabine. Aftersix cycles of therapy, the blood counts normalize and hissymptoms disappear. In 10 months, however, the whiteblood cell count is 27 x 103/L and he reports havingdrenching night sweats. He has cervical and inguinal lym-phadenopathy of one to two centimeters. Results of abiopsy of one of the nodes again shows CLL, with no evi-dence of transformation to Richters syndrome.

Which of the following treatment options is most likely toinduce a second response?

10 | Practice Test 2

A. Repeat treatment with fludarabineB. ChlorambucilC. RituximabD. AlemtuzumabE. IFN-

50. A 46-year-old man has urinary frequency and isfound to have a mass in the bladder on examinationunder anesthesia and cystoscopy. A clinical T3 lesion isdiagnosed and confirmed by biopsy findings.

Which of the following statements concerning the use ofchemotherapy for invasive bladder cancer is correct?

A. Combination chemotherapy with a cisplatin-based regimenhas been shown to improve survival when administered topatients with invasive bladder cancer in prospective ran-domized trials

B. Chemotherapy with gemcitabine and cisplatin should beadministered to all patients with extravesical extensiondocumented at cystectomy

C. Randomized comparisons of a regimen of M-VAC followedby cystectomy; cystectomy and a regimen of CMV followedby radiation or surgery; and radiation or surgery aloneshowed no benefit for early chemotherapy

D. Matched for stage and grade, a TP53-negative tumor has ahigher risk of metastatic progression than a TP53-positivetumor

E. Paclitaxel-based chemotherapy programs are standardtherapy

51. Which of the following is true about age adjustmentof incidence and mortality rates?

A. It allows for more accurate comparison of the incidence ormortality rate for two populations by removing the affect ofdifferent age distributions in those populations

B. It makes it necessary to determine the absolute number ofcancers and deaths in a population

C. It allows for more accurate five-year survival statisticsD. It allows for more accurate assessment of cancer in

younger populations

52. A 58-year-old woman is diagnosed with advancedovarian cancer. Because breast cancer developedbefore the age of 40 in two first-degree relatives (anolder sister and an aunt), the woman elects to havegenetic testing and is found to have a BRCA1 mutation.She asks your advice about the value of a prophylacticbilateral oophorectomy for her daughter (age 38), whohas also tested positive for a BRCA1 mutation.

Which of the following statements most accuratelyreflects current knowledge regarding the daughters

future risk of ovarian cancer following prophylactic bilat-eral oophorectomy?

A. This procedure will essentially eliminate the risk of anovarian-like cancer

B. This procedure has not been shown to have a substantialimpact on the subsequent development of an ovarian-likecancer

C. Because it is not possible to remove all tissue at risk, thisprocedure has little role in the prevention of ovarian-likecancers in women with a genetic abnormality

D. The procedure is safe and effective, and there will be littlenegative impact resulting from estrogen deprivation in a 38-year-old woman

E. There appears to be a substantial short-term decreasedrisk for development of an ovarian-like cancer, but long-term risk reduction remains uncertain

53. A 60-year-old man with a metastatic sarcoma to thelung and left-sided pleural effusion is being treated withhigh-dose methotrexate. Following the treatment he istreated with leucovorin as a rescue agent. The presenceof the pleural effusion will:

A. Have no effect on the methotrexate clearance or areaunder the curve

B. Increase the clearance of methotrexateC. Decrease the clearance of methotrexateD. Have no effect on the clearance of methotrexate, but will

increase the AUCE. Decrease the clearance of methotrexate and the AUC

54. A 42-year-old man presents because of rectalbleeding and tenesmus. During the interview process,he reports having substantial abdominal distention,narrowed stools, and difficulty with bowel movements.On colonoscopy, a large friable lesion is found four cen-timeters from the anal verge; it was difficult to pass thecolonoscope because of the lesion. The findings onbiopsy were positive for adenocarcinoma. Staging CTdemonstrated more than 10 hepatic lesions with sub-stantial hepatic replacement. The levels of aspartateaminotransferase and alkaline phosphatase werethree times the upper limit of normal. A surgeonrecommended a diverting colostomy, but the patient isreluctant. He presents to you for chemotherapy instead.

Which of the following would you recommend?

A. Radiation and fluorouracil for local control of the rectallesion followed by irinotecan, fluorouracil, and leucovorin

B. Abdominoperineal resection of the primary lesion followedby systemic chemotherapy

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C. Initial chemotherapy with irinotecan, fluorouracil, andleucovorin

D. Diverting colostomy followed by chemotherapy

55. For which of the following patients is high-doseinterferon therapy for stage III melanoma (node-positivedisease) contraindicated?

A. A 50-year-old man with a history of hypertension andinsulin-dependent diabetes

B. A 55-year-old woman with a history of DCIS of the left breasttreated with radiation therapy one year ago

C. A 32-year-old man with a history of hepatitis A with normalliver enzymes

D. A 35-year-old woman who has a history of significantdepression that requires chronic antidepressive medica-tions and frequent hospitalizations for depression

E. A 55-year old woman with a history of a pulmonary embo-lus four months ago who is being treated with warfarin

56. A 66-year-old man with stage IV bronchogenic can-cer metastatic to the mediastinal lymph nodes, adrenalglands, and bone presents for routine follow-up. For thepast four months, he has received chemotherapy withpaclitaxel and carboplatin. His only complaint is fatigue.The Karnofsky performance status is 70. Routine bloodwork shows a hemoglobin level of 8.7 g/dL; the hemo-globin level had been 13.2 g/dL at the start of therapy.Stool is negative for occult blood. He has been doingresearch on the Internet and is curious about whetherhe is a good candidate for erythropoietin.

Which of the following statements regarding erythropoi-etin is correct?

A. Treatment with erythropoetin should continue until thehemoglobin level increases by 1 to 2 g/dL

B. The goal should be to normalize hemoglobin levels to morethan 12 g/dL

C. Iron, total iron binding capacity, and ferritin levels shouldbe obtained at least every two months

D. Patients with myeloma should begin treatment witherythropoetin in conjunction with the start ofchemotherapy

E. Transfusion of packed red blood cells is contraindicatedbefore the initiation of erythropoietin

57. A 77-year-old man has increasing confusion. Hisfamily takes him to the emergency room, and he is foundto be dehydrated, with a serum calcium level of 10.6mg/dL, an albumin level of 3.2 g/dL, and a normal alka-line phosphatase level. The blood urea nitrogen is 44

mg/dL, which decreases to 26 mg/dL with hydration.Also found is normochromic, normocytic anemia, with ahemoglobin of 9.1 g/dL and a hematocrit of 28%.Routine chemistry studies demonstrate an increasedglobulin fraction, leading to quantitative immunoglobulindeterminations that show an IgG of 2,600 mg/dL, withnormal concentrations of IgA and IgM. Evaluation of abone marrow sample indicates that it is normocellular forage, with 7% plasma cells and Congo red staining is neg-ative. Compression fractures of vertebral bodies are seenon x-ray but no lytic lesions are seen.

Which of the following is the most likely diagnosis?

A. Waldenstrms macroglobulinemiaB. Multiple myelomaC. Monoclonal gammopathy of undetermined significance

(MGUS)D. Amyloidosis

58. Steroid hormones bind to receptors that aretranscription factors and activate the expression ofhormone-responsive genes.

Which of the following statements about steroidresponse in cancer treatment is false?

A. Expression of the estrogen receptor is associated withresponse to hormone therapy

B. Expression of the progesterone receptor is associated withresponse to megestrol acetate

C. The t(15;17) translocation in acute promyelocyticleukemia (APL) predicts for effectiveness of all-transretinoic acid

D. The level of expression of the androgen receptor does notpredict the efficacy of androgen ablation in prostate cancer

E. For advanced hormone-refractory prostate cancer, expres-sion of the androgen receptor is often increased becauseof gene amplification

59. Severe diarrhea developed in a 72-year-old patientwith rectal cancer, two weeks after treatment with an ini-tial course of continuous infusion of fluorouracil andpelvic radiation, given postoperatively because of therisk of local-regional recurrence. Treatment for the diar-rhea is begun with loperamide 2 mg for every loosestool, to a total dose of 20 mg daily.

Despite this treatment, diarrhea continues to be a sub-stantial problem, with 10 watery stools daily. The patientis otherwise in good condition and is ingesting adequateliquids to maintain normal hydration.

Which of the following medications would you recom-mend to alleviate this treatment-induced diarrhea?

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A. OctreotideB. SucralfateC. OzalazineD. Glutamine

60. A 30-year-old woman is referred by her primarycare physician for evaluation of bilateral lung nodules.Five years ago, she had total thyroidectomy for a 2.5-centimeter papillary thyroid cancer and subsequentablation of residual thyroid tissue with radioactiveiodine. She has had no subsequent treatment and waslost to follow-up. Two weeks ago, she presented to herprimary care physician with nasal congestion and acough. A chest x-ray showed small bilateral pulmonarynodules, which were confirmed by CT of the chest withintravenous contrast. The serum thyroglobulin levelwas elevated (227 ng/mL). The results of thoraco-scopic biopsy of two nodules demonstrated papillaryhistology. A diagnostic whole body scan with injectionof radioactive iodine, after recombinant thyrotropin

stimulation, revealed no evidence of iodine-aviddisease.

Currently, she is asymptomatic. Her only medication isthyroxine. On physical examination, she appears healthyand in no distress. Examination of the neck shows awell-healed surgical scar with no palpable nodules andno lymphadenopathy. The lung fields are clear to aus-cultation and percussion. The remainder of the exami-nation is unremarkable.

Which of the following is the most appropriate manage-ment?

A. Chemotherapy with a doxorubicin-based regimenB. Repeat whole body scan with injection of radioactive

iodine in six to eight weeksC. Surgical resection of the dominant pulmonary noduleD. External beam radiation therapy to the dominant pulmonary

noduleE. Octreotide scan and treatment with somatostatin if the scan

is positive for disease

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