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Practice Test 2
D. AC combined with trastuzumab
E. AC alone

1. A 52-year-old woman with stage III melanoma is receiving high-dose interferon therapy. She has completed the
four weeks of daily intravenous therapy and is now in the
fifth month of maintenance subcutaneous therapy with
interferon. Laboratory analyses performed on the previous
day demonstrated a normal complete blood count and
differential count, but the serum bilirubin was 1.9 mg/dL,
the asparate aminotransferase was 420 U/L, and the
alanine aminotransferase was 380 U/L. The patient feels
well at this time except for fatigue. A physical examination
performed last week was normal.

3. A 34-year-old woman with CML in chronic phase has

received an allogeneic bone marrow transplant without
depletion of the T cells. The transplant donor is an HLAidentical brother. The preparative regimen included busulfan and cyclophosphamide. At one year after the
transplant, disease is in morphologic and cytogenetic complete remission, but a PCR assay performed for the first
time is positive for BCR-ABL.

Which of the following treatment options would you


Which of the following statements best describes the

significance of the positive assay?


A. It has no significance
B. It increases the risk of relapse to 40%, compared with 4%
if the assay were negative
C. It increases the risk of relapse to 80%, compared with 4%
if the assay were negative
D. It represents an early indication of inevitable relapse

Continue with the current treatment plan

Discontinue interferon therapy permanently
Continue interferon, but reduce the dose by 50%
Discontinue interferon and start treatment with IL-2
E. Discontinue interferon until the liver function tests normalize, then restart interferon at a 50% dose reduction

2. A 38-year-old premenopausal woman is referred for

treatment of metastatic breast cancer. She was diagnosed 18 months earlier with a T1, N0, M0, poorly differentiated invasive ductal cancer that was ER negative,
PR negative, and HER2 positive (3+ staining). The primary tumor was 0.6 centimeters in the largest diameter.
She was treated with a total mastectomy and axillary
dissection; of 16 lymph nodes removed, all were negative for disease. No adjuvant systemic therapy was
The current evaluation now demonstrates bilateral,
asymptomatic pulmonary metastases, a small left pleural
effusion, and multiple areas of increased uptake on bone
scan, involving the ribs, spine, and pelvis. X-rays of the
bone are remarkably unimpressive, showing one five-centimeter lytic lesion in the right ileum. Cytologic analysis of
pleural fluid is positive for adenocarcinoma cells, consistent with the earlier diagnosis of breast cancer.
In addition to intravenous bisphosphonate therapy,
which of the following would you recommend?
A. Classical CMF
B. Weekly intravenous trastuzumab alone
C. Paclitaxel combined with trastuzumab

4. A 55-year-old man presents because of multiple lung

and liver metastases found on routine follow-up CT two
years after treatment for stage III cancer of the sigmoid
colon. He was treated with resection and postoperative
adjuvant chemotherapy with fluorouracil and leucovorin.
Examination of a biopsy sample of the liver lesion
demonstrates adenocarcinoma consistent with a
primary cancer of the colon. The results of laboratory
tests are as follows: total bilirubin, 2.1 mg/dL; creatinine,
0.8 mg/dL; alkaline phosphatase, 108 U/L; aspartate
aminotransferase, 22 U/L; alanine aminotransferase, 12
U/L; and albumin, 4.0 g/dL. He is eager to begin treatment and understands that no treatment offers curative
Which of the following would you recommend?
A. Irinotecan, fluorouracil, and leucovorin as a bolus administration
B. Irinotecan, fluorouracil, and leucovorin as an infusion
C. Capecitabine as single-agent therapy
D. Oxaliplatin, fluorouracil, and leucovorin
E. No therapy because the patient is asymptomatic and
chemotherapy offers no survival benefit

5. Which of the following histologic subtypes of Hodgkins lymphoma is most likely to respond to treatment with rituximab?
Practice Test 2 |


Nodular sclerosing
Nodular lymphocyte-predominant
Mixed cellularity
Lymphocyte depleted
None of the above

6. A 60-year-old woman at high risk of breast cancer

because of an extensive family history and a personal
history of lobular carcinoma in situ asks what her
options are for decreasing her risk of breast cancer risk.
Which of the following measures has been demonstrated in clinical trials to decrease the five-year risk of
breast cancer for this woman?

Tamoxifen therapy
Raloxifene therapy
Annual mammography
Adoption of a low-fat diet

7. A 72-year-old man presents with symptomatic bone

metastases secondary to prostate cancer. The baseline
hemoglobin was 11 g/dL and the PSA level at the start
of hormone treatment was 250 ng/mL. Androgen ablation was initiated with a three-month depot of goserelin,
a gonadotropin-releasing hormone analogue, and the
antiandrogen bicalutamide. After six months of therapy,
the symptoms improved, and the level of PSA was undetectable. He continued to be monitored every three
months. At month 18, the PSA level was 10 ng/mL, with
no change in other parameters. A repeat PSA level was
15 ng/mL. A testosterone level is at castrate level.
Bisphosphonate therapy was initiated recently.
Which of the following should be the next intervention?

Ketoconazole and hydrocortisone
Change to a different bisphosphonate
Discontinue bicalutamide but continue therapy with goserelin
Strontium-89 or samarium-153

8. A 62-year-old man presents for routine outpatient follow-up eight months after completing initial treatment
with concurrent cisplatin-based chemoradiotherapy for
T3, N2b, M0 squamous cell cancer of the right tonsil.
He was rendered free of disease. He has had mild dysphagia and odynophagia for approximately three weeks.
He is otherwise asymptomatic and reports having no
fever, chills, nausea, vomiting, weight loss, cough,
hemoptysis, or trismus. He continues to work full-time.
On physical examination, a recurrent ulcerated mass is
clearly noted in the area of the right tonsil, with exten2

| Practice Test 2

sion into the soft palate; it is clinically T3 in extent.

Evaluation of the neck reveals changes as a result of
radiation but no clear evidence of recurrent disease. The
remainder of the physical examination is unremarkable.
The results of a complete blood count, serum chemistry
tests, and liver function tests are within normal limits. CT
of the neck confirms the recurrent tonsillar mass. A
chest x-ray and other diagnostic evaluations show no
evidence of distant metastases. Analysis of a biopsy
specimen from the tonsillar mass demonstrates a poorly
differentiated squamous cell cancer. Consultation with a
radiation oncologist indicates that the recurrence is
squarely within the prior radiation field.
Which of the following is the most appropriate therapy
for this patient?
A. Single-agent chemotherapy
B. Combination chemotherapy
C. Salvage-combined chemoradiotherapy with intensity-modulated radiotherapy
D. Referral to a head and neck surgeon

9. IFN-2 has been demonstrated to have clinically significant single-agent antitumor activity against which one
of the following malignant diseases?

Chronic myelogenous leukemia

Acute myelogenous leukemia
Metastatic colorectal cancer
Acute lymphocytic leukemia (non-T cell)
Small cell bronchogenic cancer

10. A 59-year-old man is referred for evaluation of persistent lymphocytosis. On physical examination, he is
found to have cervical, axillary, and inguinal lymphadenopathy. The white blood cell count is 19,000/L.
Your differential diagnosis includes CLL.
Which of the following tests is most likely to yield the

Lymph node biopsy

Bone marrow biopsy
Examination of the peripheral blood
Immunophenotyping of peripheral blood lymphocytes

11. Which one of the following statements most

accurately describes trends in the incidence of breast
A. The incidence of breast cancer is decreasing in industrialized countries. It is estimated that 150,000 new cases will
be diagnosed worldwide in 2004, and a similar number in
the United States

B. The incidence of breast cancer is higher in developing

countries than in the industrialized world. More than two
million cases will be diagnosed worldwide in 2004,
300,000 of them in the United States
C. The incidence of breast cancer has been increasing gradually for the past 25 years. It is estimated that in 2004,
breast cancer will develop in 217,440 women in the
United States and in 1,300 men
D. In western industrialized countries, breast cancer is the
third most common cancer among women, accounting for
900,000 cases in the United States and Western Europe
E. Lung cancer has displaced breast cancer as the most
common cancer among women in the United States; since
the introduction of screening mammography, fewer than
100,000 new cases of breast cancer are diagnosed yearly
in the United States

12. A 26-year-old woman presents for a second opinion

regarding the management of melanoma. Five years ago,
she was treated for a malignant melanoma on the lower
part of the abdomen. The melanoma was 0.9 millimeter
thick, there was no ulceration, and the Clark level was III.
She was treated with wide excision that showed no residual melanoma and was then monitored. She now has an
enlarged right inguinal lymph node that measures 2.5
centimeters by 2.0 centimeters. The lymph node is
removed and is positive for melanoma. A staging work-up,
including CT of the chest, abdomen, and pelvis, is negative for metastatic disease.

D. Maintain full doses of capecitabine and closely monitor the

coagulation parameters
E. Reduce the oxaliplatin dose because full doses are known
to worsen the renal function of patients with preexisting

14. A radiograph of the right humerus of an 18-year-old

woman with pain just distal to the shoulder shows a scleorotic humeral lesion with evidence of destruction of the
cortex 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 sarcoma evident on the radiograph includes which of the
A. Surgery only
B. Surgery and radiation therapy
C. Surgery and chemotherapy
D. Surgery, radiation therapy, and chemotherapy

15. A 62-year-old man presents with a one-month history of cough. Over the last week, he has had several
episodes of hemoptysis. On review of symptoms, he also
reports that he has had increasing fatigue, decreased
appetite, and a loss of five to 10 pounds. He has no
other meaningful medical history and has otherwise
been well. He smokes approximately two packs of cigarettes daily.

Which of following treatment options would you now

recommend to this patient?

Isolated limb perfusion

Complete inguinal lymph node dissection
High-dose interferon therapy
No further therapy
Radiation therapy to the inguinal lymph node basin

13. A 62-year-old woman will begin treatment for

metastatic colon cancer. She is strongly in favor of
receiving capecitabine in combination with oxaliplatin.
Currently, she is taking a beta blocker for hypertension,
warfarin for atrial fibrillation, and estrogen for postmenopausal symptoms.
Which of the following is appropriate?
A. Use capecitabine at full doses but change the beta blocker
to an angiotensin converting enzyme (ACE) inhibitor
B. Reduce the capecitabine dose to avoid an interaction with
the warfarin
C. Stop the estrogen-replacement therapy, as it is contraindicated for patients with colon cancer

Figure 1.

Practice Test 2 |

On physical examination, he appears well developed

and well nourished, and the ECOG performance status
of 1. No focal physical findings are noted. A chest x-ray
demonstrates a large right hilar mass. CT of the chest
confirms the hilar mass, a large, bulky, right-sided mediastinal adenopathy, and no other pulmonary, adrenal, or
liver lesions. The findings on bone scan and on CT of the
head made with contrast medium are negative. The
results of percutaneous needle biopsy are positive for
small cell cancer.
Which of the following is most likely to yield long-term
A. Cisplatin and etoposide followed by radiation therapy to the
thorax at 60 Gy administered in daily fractions over six weeks
B. Cisplatin and etoposide plus concurrent radiation therapy
to the thorax at 45 Gy administered in daily fractions over
five weeks
C. Cisplatin and etoposide followed by radiation therapy to the
thorax at 45 Gy administered twice daily over three weeks
D. Cisplatin and etoposide plus concurrent radiation therapy to
the thorax at 45 Gy administered twice daily over three
E. Cisplatin and etoposide, with radiation therapy at 45 Gy
administered on relapse of disease

16. The patient described in question 15 has a complete

response to combined-modality treatment. You decide to
discuss prophylactic cranial radiation with him.

patients condition appears to be improved but she

has persistent disease, which is confirmed by CT. Two
months after the completion of chemoradiotherapy,
the patient reports having back pain that prevents her
from sleeping. She also notes a major decrease in
appetite and a loss of 15 pounds over the past month.
A repeat CT scan demonstrates a number of newly
enlarged retroperitoneal lymph nodes (three to four
centimeters in diameter), a growing pelvic mass (four
centimeters by five centimeters), and several pulmonary nodules (one to three centimeters), which
were 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 ifosfamide
C. Pelvic exenteration followed by surgical removal of the
pulmonary nodules
D. Palliative measures to treat symptoms and provide comfort
E. Whole abdomen radiation therapy followed by cisplatinbased chemotherapy

18. In addition to a history and physical examination,

which of the following procedures should be included
for the optimal surveillance of patients with primary
breast cancer after local, regional, and systemic therapies have been completed?

A. Prophylactic cranial radiation decreases the morbidity

associated with brain metastases but at the price of a
decrease in cognitive function and with no improvement in
B. Prophylactic cranial radiation decreases the morbidity
associated with brain metastases without any significant
impact on cognitive function and no improvement in survival
C. Prophylactic cranial radiation decreases the morbidity
associated with brain metastases and improves survival but
with increased long-term cognitive defects
D. Prophylactic cranial radiation decreases the morbidity
associated with brain metastases and improves survival,
with minimal long-term cognitive defects

A. History and physical examination every four to six months

during the first five years and yearly thereafter. Annual
mammography of the remaining breast tissue
B. History and physical examination, complete blood count,
and liver function tests every four to six months during the
first five years and yearly thereafter. Annual mammography
of the remaining breast tissue
C. History and physical examination, complete blood count,
liver function tests, and tumor markers every four to six
months 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 abdominal imaging every four to six months during the first five
years and yearly thereafter. Annual mammography of the
remaining breast tissue
E. Whole-body PET every four to six months during the first
five years, then yearly thereafter

17. A 45-year-old woman is found to have a locally

advanced cervical cancer that is treated with external
beam radiation therapy along with weekly cisplatin (40
mg/m2). At the completion of radiation therapy, the

19. Which cytogenetic abnormality and resulting protein

are associated with the lymphoma associated with the
highest likelihood of cure?

In addition to reducing brain recurrence, which of the

following statements is true regarding the use of radiation therapy in this setting?

| Practice Test 2


t(11;14) and cyclin D1

t(14;18) and BCL-2
t(2;5) and ALK
t(9;14) and PAX-5
t(1;14) and CARD

20. A 75-year-old man with chronic heart failure and

dementia had a left hemicolectomy for colon cancer.
The proximal and distal margins of resection are free of
tumor within more than four centimeters. Metastasis is
identified in three of 10 lymph nodes. The patient is fully
ambulatory, lives with his wife of 40 years, and is taking
the following medications: simvastatin and hydrochlorthiazide. You are consulted regarding the need for additional therapy.
Which of the following do you recommend?
A. No additional therapy
B. Six cycles of adjuvant therapy with fluorouracil and leucovorin
C. Six cycles of adjuvant therapy with irinotecan, fluorouracil,
and leucovorin
D. Radiation therapy to the primary tumor site and regional
lymph nodes
E. Six cycles of fluorouracil/leucovorin and oxaliplatin

21. A 55-year-old woman with breast cancer that is

metastastic to the bone presents because of substantial
pain that is not well controlled with a nonsteroidal antiinflammatory drug. Her physician decides to begin treatment with a narcotic. The patient is educated with
regard to the side effects of narcotic medications and is
told that many of the side effects are temporary but that
tolerance generally does not develop to one side effect,
making it a chronic toxicity that may need to be chronically managed with other medications.
Which of the following side effects is this chronic toxicity that oftentimes needs ongoing management?
A. Nausea
B. Sedation
C. Constipation
D. Cognitive impairment

22. A 52-year-old man presents with a cough of several

weeks duration but without any other symptoms. He is
able to perform normal activities. A mediastinal mass is
identified on routine chest x-ray, and right supraclavicular node, two centimeters by three centimeters, is found
on physical examination. Results from biopsy of the node
establishes the diagnosis of diffuse large B-cell non-

Hodgkins lymphoma. Additional staging includes negative findings on bone marrow biopsy. CT shows multiple
two to three-centimeter retroperitoneal nodes. PET
scanning does not identify any other sites of disease.
Laboratory evaluation includes normal levels of liver
enzymes except for an LDH of 350 U/L. The plan is to
treat him with CHOP chemotherapy.
Which of the following are the likelihood of complete
response and the five-year disease-free survival?




23. A 61-year-old woman is noted to have bilateral

axillary and inguinal adenopathy with no hepatosplenomegaly during a routine physical examination
demonstrates. She says that she has not had fevers,
chills, or sweats. The results of a complete blood count
include a white blood cell count of 21,000/L, with 79%
apparently mature lymphocytes, and a hematocrit of
35%. The platelet count is 86,000/L. A repeat platelet
count two weeks later is 59,000/L. Immunophenotyping confirms the tentative diagnosis of CLL. Further
staging includes a bone marrow aspiration and biopsy,
the results of which indicate diffuse bone marrow infiltration by 60% lymphocytes, with normal numbers of
erythroid precursors and megakaryocytes.
Which of the following statements is correct?
A. She has stage I disease and requires no therapy
B. She has stage I disease and requires treatment with corticosteroids
C. She has stage I disease and requires treatment with fludarabine
D. She has stage IV disease and requires treatment with
E. She has stage IV disease and requires treatment with

24. Clustering of multiple cases of breast and other

cancers has been observed in some families.
Which of the following statements best describes the
association of genetic abnormalities with specific familial breast cancer syndrome?
A. RB translocation is associated with Cowdens syndrome
B. BRCA2 mutations are associated with Li-Fraumeni syndrome
C. AKT mutations are associated with familial estrogen-excess
Practice Test 2 |

D. TP53 mutation is associated with Li-Fraumeni syndrome

E. Estrogen receptor gene is hypermethylated and inactive in
tumors with BRCA2 mutations

25. A 53-year-old woman has testing of bone mineral

density as part of a general health evaluation. She has a
history of breast cancer that was appropriately treated in
the past. She has no evidence of residual or recurrent
disease and her prognosis is good. The results of bone
mineral density testing demonstrate a T score of -1.0,
which is an indication of mild osteopenia but not osteoporosis. The patient has no family history of osteoporosis. Her diet does not include many dairy products.
Which of the following should you recommend for this
A. Calcium and vitamin D
B. Calcitonin
C. A bisphosphonate
D. Vitamin E

26. A 47-year-old woman presents for a screening mammogram. Her mother, who is Jewish, had breast cancer at
age 36. A maternal aunt had breast cancer at age 40. The
woman has two preteen daughters. She has no siblings. A
mammogram detects a 0.8-centimeter suspicious abnormality in the lateral portion of the right breast. The patient
and her mother become very anxious, and before any
additional diagnostic work-up they request genetic testing.
Who should be tested?

Elder daughter
Younger daughter

27. With regard to the patient described in question 26,

which of the following techniques should be used for the
genetic testing?

Southern blotting
Comparative genomic hybridization
cDNA microarray analysis
Taqman assay

28. Initial testing is carried out for the patient described

in question 26, and the results are negative. The family
wishes to have a more thorough genetic evaluation.
They are willing to pay the expenses themselves.
Which of the following tests should be done next?

| Practice Test 2


Nucleotide sequencing
Comparative genomic hybridization
cDNA microarray analysis
Taqman assay

29. With regard to the patient described in question 26,

needle-localization procedure is carried out on the mass
that appeared as an abnormality on mammography, and
evaluation of the specimen indicates ductal cancer that
is HER2 negative. Lumpectomy is done, and evaluation
of the mass demonstrates that it is an intraductal cancer
with clean margins and a single area of microinvasion.
The sentinel nodes are negative for disease. The patient
is well educated and wants the most up-to-date molecular testing done to assist in determining the prognosis
and need for chemotherapy.
Which of the following tests should be carried out on the
specimen obtained at lumpectomy?
A. Comparative genomic hybridization
B. Determination of ER and PR status and S-phase fraction
and ploidy analysis
C. cDNA microarray analysis
D. Protein truncation assay
E. Karyotyping

30. With regard to the patient described in question 26,

the genetic analysis of the mother is delayed because of
technical problems. However, the aunt has determined
that she carries a BRCA2 mutation. The patient is anxious and wants advice about minimizing her long-term
risk of breast cancer risk.
Which of the following would you recommend?

Daily aspirin
Prophylactic bilateral mastectomy
B and C
None of the above

31. A 40-year-old woman presents with hematuria. A CT

scan shows an eight-centimeter mass in the left kidney.
The findings of physical examination are negative, and a
complete blood count and screening profile are within normal limits. A CT scan of the chest shows four lesions on the
right 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 management
approach not include?

A. Resection of the renal mass followed by administration of

B. Resection of all disease followed by administration of highdose IL-2
C. Observation
D. Treatment wih low-dose IL-2
E. Resection of the pulmonary lesions followed by resection
of the primary tumor

32. Which of the following is the most favorable cytogenetic finding in patients with CLL?

Normal cytogenetic characteristics

Trisomy 12

33. Clinical trials with taxanes in the adjuvant setting that

have been reported to date have led to several conclusions.
Which of the following statements is the most accurate
with respect to taxanes?
A. Paclitaxel is more effective than docetaxel in the adjuvant
B. Docetaxel is more effective than paclitaxel in the adjuvant
C. The addition of a taxane to an established anthracyclinecontaining chemotherapy regimen improves disease-free
and overall survival rates
D. Taxanes reduce the need for breast reconstruction
E. 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 completing therapy for high-risk stage II breast cancer.
Treatment included lumpectomy, radiation therapy, and
adjuvant chemotherapy with cyclophosphamide and
doxorubicin. She now has new-onset anemia and thrombocytopenia and is found to have AML with inv(16).

35. Which of the following describes some of the differences between atypical carcinoid and small cell lung
A. Small cell lung cancer cells have a greater number of
neuroendocrine granules as detected by electron
B. Small cell lung cancer cells have a greater number of
mitoses found by light microscopy
C. Atypical carcinoids found in the lung are likely to represent metastases from the gastrointestinal tract, whereas
small cell lung cancer is almost always primary to the lung
D. Atypical carcinoids are more likely to be associated with

36. Fourteen days ago, a 40-year-old man with acute

lymphocytic leukemia in second relapse received an
infusion of G-CSF-mobilized peripheral blood stem cells
from a matched unrelated donor following a conditioning regimen of cyclophosphamide and total-body
radiation. He is now being evaluated for the recent onset
of jaundice.
On physical examination, scleral icterus is noted. A mild
erythematous rash is also observed on the upper part of
the back, and the patient reports that it has been present for two days. The liver is palpable two fingerbreadths
below 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 pounds
over the past week. After a nadir peripheral white blood
cell count following transplantation, the count has recovered to 0.7  103/L and the platelet count is
40,000/L. The results of liver function tests have
become increasingly abnormal, with a serum bilirubin of
6 mg/dL, a serum aspartate aminotransferase of 160
U/L, and a serum alanine aminotransferase of 420 U/L.
Which of the following is the most likely cause of the
patients clinical condition?

Which of the following statements is true?

A. Because of the timing of the leukemia, it is highly unlikely
that 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 previous
C. The leukemia may be associated with the previous therapy
and, therefore, although inv(16) is usually associated with
a high rate of complete response, that is not the case for
this patient
D. The leukemia may be associated with the previous therapy,
but given the inv(16), a high rate of complete response can
be expected


Allogeneic engraftment syndrome

Graft-versus-host disease
Biliary sludge associated with hyperalimentation
Veno-occlusive disease of the liver
Cyclosporine toxicity

37. Which of the following describes the cancer mortality rate of a country?
A. Percentage of patients with cancer in a country who die
from cancer each year
B. Absolute number of patients with cancer in a country who
die of cancer in a given year
Practice Test 2 |

C. Number of people who die of cancer per 100,000 individuals living in the country in a given year
D. Number of people diagnosed with potentially fatal cancers
per 100,000 cases per year

38. A 62-year-old woman who has had pelvic discomfort

for several months is found to have an enlarged left
ovary. The CA-125 antigen level is 97 U/mL. The patient
is referred to a gynecologic oncologist who performs a
laparotomy with a definitive resection of the mass.
Pathologic review indicates a stage I (grade 3) epithelial
ovarian cancer.
Which of the following is the most appropriate next step
in the treatment of this patient?
A. CT of the abdomen and pelvis every eight weeks for three
B. Six courses of a platinum (cisplatin or carboplatin)-based
C. Physical examination and measurement of the CA-125
antigen level every three months for two years, then every
six months for three years then yearly
D. Repeat exploration by laparotomy or laparoscopy in one
E. Whole abdomen radiotherapy followed by four cycles of
platinum-based chemotherapy

39. A 68-year-old woman is referred to you for additional treatment four weeks after surgical resection for a
tumor in the ascending colon that was determined on
pathologic evaluation to be a moderately differentiated
adenocarcinoma of the colon arising from a villous
adenoma. The tumor had penetrated through the
serosa, and three of 12 lymph nodes were positive for
metastatic cancer. No other disease was seen at the
time of surgery.
Preoperatively, the CEA level was 1.2 ng/mL, and CT of
the chest, abdomen, and pelvis demonstrated no
She has recovered from surgery well except for a slow
recovery of normal bowel function, with two to three
stools a day, compared with one stool per day preoperatively. Her history includes diabetes controlled with oral
agents, hypertension poorly controlled with a betablocker and a diuretic, and a hysterectomy for fibroids.
She lives with her husband, is active, and is able to drive
and maintain her own household.
Which of the following would you recommend?
A. 12 months of treatment with fluorouracil and leucovorin
B. Six months of treatment with fluorouracil, leucovorin, and

| Practice Test 2

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

D. Six months of treatment with fluorouracil and leucovorin
E. No treatment

40. A 67-year-old woman presents for a bimonthly

evaluation, and recurrence of lymphedema and axillary adenopathy is noted. The woman was first seen
one year ago for a left supraclavicular and axillary
adenopathy that was asymptomatic. At that time, a follicular lymphoma was identified at that site only. She
was observed with no therapy for six months, at which
time chemotherapy with CHOP was initiated because
the size of the axillary nodes had increased, causing
mild lymphedema. After six cycles of treatment, no
disease was evident on computerized tomography.
She returned three months later with recurrence of
edema; on restaging, new mediastinal adenopathy
was found, in addition to recurrence in the axillary and
supraclavicular nodes. The findings of repeat biopsy
confirmed follicular lymphoma. Treatment with rituximab was started and was complicated by mild wheezing and fever on the first day of infusion. After two
monthly cycles of rituximab, complete regression was
confirmed and treatment was discontinued.
At the present time, nine months after treatment was
discontinued, the lymphocyte count is 900/mm3 and the
complete blood count and chemistry panel are otherwise unremarkable.
When considering treatment options, which of the
following should influence your thinking regarding
A. It is likely she will have neutralizing antibodies to rituximab that will negate its therapeutic activity
B. Because of her history of wheezing on the first day of
infusion of the drug, there is a strong possibility of anaphylaxis during re-treatment
C. Response rates associated with rituximab as re-treatment
are essentially equivalent to those for patients who have
had a previous response
D. Aletuzemab is a noncross-reactive antibody to CD20 and
should be given
E. A cytokine-release syndrome can be expected to develop
on re-treatment

41. A 70-year-old man presents with a three-week history

of increasing weakness of the left arm and leg. The medical history indicates no evidence of prior malignant disease, recent infection, or use of immunosuppression. On
physical examination, he has reduced strength in the left

ation of multiagent HIV therapy, but decreased to less

than 100/L over the past three years.
Physical examination demonstrates a left cervical
mass (six by eight centimeters). The findings on CT
and a gallium scan show disease confined to the left
side of the neck. Evaluation of bone marrow and a
biopsy specimen shows involvement with lymphoma.
The morphologic and phenotypic studies of the
tissue from the neck mass confirm the diagnosis of
What is the likely histologic type of lymphoma in this
clinical setting?

Figure 2.

arm and leg, but there is no adenopathy or other abnormal findings.

Magnetic resonance imaging (MRI) shows a solitary
uniformly contrast-enhanced mass lesion in the right
posterior frontal lobe (Fig. 2). Tumor specimen obtained
by biopsy indicates large B-cell lymphoma. The complete blood count; serum chemistries levels, including
liver enzymes and LDH; and HIV serology are normal, as
are the findings on slit lamp eye examination. The
results of CT of the chest, abdomen, and pelvis are normal. The results of MRI of the spine are unremarkable,
and no malignant cells are found on cytologic analysis of
cerebrospinal fluid.
Which of the following is the best treatment option?
A. Whole-brain radiation therapy
B. Excision of the mass lesion
C. Chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP)
D. High-dose methotrexate-based chemotherapy
E. Concurrent methotrexate-based chemotherapy and wholebrain radiation therapy

42. A 39-year-old patient with a history of hemophilia A

presents with a three-week history of an enlarging gland
on the left side of the neck. Infection with HIV was diagnosed five years earlier and treated initially with zidovudine (AZT) and then with combination therapy
containing a nucleoside analogue (D4T) and an HIV protease inhibitor. The CD4 count increased after the initi-

T-cell large lymphoma

Large B-cell lymphoma
Non-T cell, non-B-cell lymphoma
Natural killer cell lymphoma

43. Referring to the patient described in question 42,

which of the following statements is true about what the
diagnostic lymphoid tissue will carry?

HHV-8, with 100% probability

EBV, with 100% probability
EBV, with less than 50% probability
Human papillomavirus with 100% probability

44. A 53-year-old premenopausal woman is found to

have a small palpable mass in the upper, inner quadrant
of the left breast. On physical examination, the mass is
estimated to be 1.2 centimeters in largest diameter. No
regional lymph nodes were palpable. Bilateral mammography confirms the presence of a stellate mass in
the upper, outer quadrant of the left breast. There are
also diffuse calcifications throughout the upper, inner
quadrant of the left breast and in two separate areas of
the right breast.
The results of stereotactic biopsy of the original abnormality on the left side indicate an area of infiltrating ductal cancer with DCIS. The invasive tumor is ER positive,
PR positive, and HER2 negative. The findings of biopsy
of the two additional abnormalities of the left breast
demonstrate mixed ductal and lobular carcinoma in
situ. A biopsy specimen is obtained from the right
breast, and the results indicate that the abnormalities on
mammography were benign.
Which of the following is the preferred treatment option
for this patient?
A. Lumpectomy, axillary dissection, radiation therapy, four
cycles of AC, and trastuzumab for one year
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B. Total left mastectomy with immediate breast reconstruction, sentinel lymph node biopsy, four cycles of AC, and
tamoxifen for five years
C. Bilateral simple mastectomy with left sentinel node biopsy
and anastrozole for five years
D. Lumpectomy, bilateral breast radiation therapy, and tamoxifen for five years
E. Radiofrequency ablation of all three abnormal areas of
the breast, axillary dissection, radiation therapy, and
tamoxifen for five years followed by letrozole for five

45. A 32-year-old man presents with a four-week history

of a cough and an enlarging testicular mass. The evaluation shows five pulmonary nodules in the left lung; the
largest is 1.5 centimeters. A CT scan of the abdomen
shows multiple enlarged nodes in the retroperitoneum
(maximum size, 10 centimeters). Laboratory values
include a lactate dehydrogenase level of 800 U/L, an
alpha-fetoprotein level of 3,500 units and an HCG level
of 4 mIU/mL. The testicular mass is removed and the
pathologic diagnosis is embryonal cancer with elements
of choriocarcinoma and teratoma is made. He receives
three cycles of cisplatin, etoposide, and bleomycin, with
resolution of symptoms and normalization of markers.
Imaging studies after the three cycles of chemotherapy
show no evidence of disease in the chest, but the
abdominal examination reveals a three-centimeter
residual mass in the retroperitoneum.
Which of the following would you recommend?
A. FDG-PET and observation to ensure that there is no residual
B. Change in therapy to vinblastine, ifosfamide, and cisplatin
C. Two additional cycles of cisplatin, etoposide, and
D. Surgical exploration of the abdomen, with dissection of
retroperitoneal lymph nodes
E. Radiation therapy to the abdomen

46. Which of the following is true regarding screening for

lung cancer?
A. In randomized screening studies conducted during the
1980s, chest x-rays with or without cytologic analysis of
sputum failed to detect earlier stage cancers in screened
B. Low-dose, thin-slice spiral CT, without the use of contrast
medium, is more sensitive than chest x-rays for the detection of lung nodules and lung cancer at early stages
C. Although screening with low-dose, thin-slice spiral CT,


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without the use of contrast medium, has an impact on the

mortality related to lung cancer, the technique is not costeffective for lung cancer screening
D. Low-dose, thin-slice spiral CT, without the use of contrast
medium, is more effective than chest x-rays at differentiating cancers from granulomatous disease

47. Which of the following is true regarding neoadjuvant

(preoperative) chemotherapy for stage I, II, and III disease?
A. Neoadjuvant chemotherapy has improved survival in large,
randomized phase III trials
B. The primary role of neoadjuvant chemotherapy is to render
unresectable disease resectable
C. Neoadjuvant chemotherapy does not affect postoperative
D. Survival is better for patients who have pathologically staged
N2 nodes downstaged to N0 following neoadjuvant chemotherapy than for patients whose nodes were not downstaged

48. Clinical trials have demonstrated that the risk of

breast cancer can be reduced by several medical interventions.
Which of the following statements is false?
A. Prophylactic bilateral mastectomy is associated with a
marked reduction in the risk of breast cancer
B. Prophylactic bilateral ovarian ablation before age 45 is
associated with a substantial reduction in risk, even for
women with familial breast cancer
C. For postmenopausal women, hormone-replacement therapy
using a combination of estrogens and progestins substantially reduces the risk of breast cancer
D. Tamoxifen administered for five years is associated with a
30% to 50% reduction in risk
E. Selective aromatase inhibitors are associated with considerable reductions in the incidence of second primary
breast cancers

49. A 59-year-old man is diagnosed with CLL. Because of

disease-related symptoms and a rapidly increasing lymphocyte count, therapy is initiated with fludarabine. After
six cycles of therapy, the blood counts normalize and his
symptoms disappear. In 10 months, however, the white
blood cell count is 27 x 103/L and he reports having
drenching night sweats. He has cervical and inguinal lymphadenopathy of one to two centimeters. Results of a
biopsy of one of the nodes again shows CLL, with no evidence of transformation to Richters syndrome.
Which of the following treatment options is most likely to
induce a second response?


Repeat treatment with fludarabine


50. A 46-year-old man has urinary frequency and is

found to have a mass in the bladder on examination
under anesthesia and cystoscopy. A clinical T3 lesion is
diagnosed and confirmed by biopsy findings.
Which of the following statements concerning the use of
chemotherapy for invasive bladder cancer is correct?
A. Combination chemotherapy with a cisplatin-based regimen
has been shown to improve survival when administered to
patients with invasive bladder cancer in prospective randomized trials
B. Chemotherapy with gemcitabine and cisplatin should be
administered to all patients with extravesical extension
documented at cystectomy
C. Randomized comparisons of a regimen of M-VAC followed
by cystectomy; cystectomy and a regimen of CMV followed
by radiation or surgery; and radiation or surgery alone
showed no benefit for early chemotherapy
D. Matched for stage and grade, a TP53-negative tumor has a
higher risk of metastatic progression than a TP53-positive
E. Paclitaxel-based chemotherapy programs are standard

51. Which of the following is true about age adjustment

of incidence and mortality rates?
A. It allows for more accurate comparison of the incidence or
mortality rate for two populations by removing the affect of
different age distributions in those populations
B. It makes it necessary to determine the absolute number of
cancers and deaths in a population
C. It allows for more accurate five-year survival statistics
D. It allows for more accurate assessment of cancer in
younger populations

52. A 58-year-old woman is diagnosed with advanced

ovarian cancer. Because breast cancer developed
before the age of 40 in two first-degree relatives (an
older sister and an aunt), the woman elects to have
genetic testing and is found to have a BRCA1 mutation.
She asks your advice about the value of a prophylactic
bilateral oophorectomy for her daughter (age 38), who
has also tested positive for a BRCA1 mutation.
Which of the following statements most accurately
reflects current knowledge regarding the daughters

future risk of ovarian cancer following prophylactic bilateral oophorectomy?

A. This procedure will essentially eliminate the risk of an
ovarian-like cancer
B. This procedure has not been shown to have a substantial
impact on the subsequent development of an ovarian-like
C. Because it is not possible to remove all tissue at risk, this
procedure has little role in the prevention of ovarian-like
cancers in women with a genetic abnormality
D. The procedure is safe and effective, and there will be little
negative impact resulting from estrogen deprivation in a
38-year-old woman
E. There appears to be a substantial short-term decreased
risk for development of an ovarian-like cancer, but longterm risk reduction remains uncertain

53. A 60-year-old man with a metastatic sarcoma to the

lung and left-sided pleural effusion is being treated with
high-dose methotrexate. Following the treatment he is
treated with leucovorin as a rescue agent. The presence
of the pleural effusion will:
A. Have no effect on the methotrexate clearance or area
under the curve
B. Increase the clearance of methotrexate
C. Decrease the clearance of methotrexate
D. Have no effect on the clearance of methotrexate, but will
increase the AUC
E. Decrease the clearance of methotrexate and the AUC

54. A 42-year-old man presents because of rectal

bleeding 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 centimeters from the anal verge; it was difficult to pass the
colonoscope because of the lesion. The findings on
biopsy were positive for adenocarcinoma. Staging CT
demonstrated more than 10 hepatic lesions with substantial hepatic replacement. The levels of aspartate
aminotransferase and alkaline phosphatase were
three times the upper limit of normal. A surgeon
recommended a diverting colostomy, but the patient is
reluctant. He presents to you for chemotherapy instead.
Which of the following would you recommend?
A. Radiation and fluorouracil for local control of the rectal
lesion followed by irinotecan, fluorouracil, and leucovorin
B. Abdominoperineal resection of the primary lesion followed
by systemic chemotherapy
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C. Initial chemotherapy with irinotecan, fluorouracil, and

D. Diverting colostomy followed by chemotherapy

55. For which of the following patients is high-dose

interferon therapy for stage III melanoma (node-positive
disease) contraindicated?
A. A 50-year-old man with a history of hypertension and
insulin-dependent diabetes
B. A 55-year-old woman with a history of DCIS of the left breast
treated with radiation therapy one year ago
C. A 32-year-old man with a history of hepatitis A with normal
liver enzymes
D. A 35-year-old woman who has a history of significant
depression that requires chronic antidepressive medications and frequent hospitalizations for depression
E. A 55-year old woman with a history of a pulmonary embolus four months ago who is being treated with warfarin

56. A 66-year-old man with stage IV bronchogenic cancer metastatic to the mediastinal lymph nodes, adrenal
glands, and bone presents for routine follow-up. For the
past four months, he has received chemotherapy with
paclitaxel and carboplatin. His only complaint is fatigue.
The Karnofsky performance status is 70. Routine blood
work shows a hemoglobin level of 8.7 g/dL; the hemoglobin level had been 13.2 g/dL at the start of therapy.
Stool is negative for occult blood. He has been doing
research on the Internet and is curious about whether
he is a good candidate for erythropoietin.
Which of the following statements regarding erythropoietin is correct?
A. Treatment with erythropoetin should continue until the
hemoglobin level increases by 1 to 2 g/dL
B. The goal should be to normalize hemoglobin levels to more
than 12 g/dL
C. Iron, total iron binding capacity, and ferritin levels should
be obtained at least every two months
D. Patients with myeloma should begin treatment with
erythropoetin in conjunction with the start of
E. Transfusion of packed red blood cells is contraindicated
before the initiation of erythropoietin

57. A 77-year-old man has increasing confusion. His

family takes him to the emergency room, and he is found
to be dehydrated, with a serum calcium level of 10.6
mg/dL, an albumin level of 3.2 g/dL, and a normal alkaline phosphatase level. The blood urea nitrogen is 44

| Practice Test 2

mg/dL, which decreases to 26 mg/dL with hydration.

Also found is normochromic, normocytic anemia, with a
hemoglobin of 9.1 g/dL and a hematocrit of 28%.
Routine chemistry studies demonstrate an increased
globulin fraction, leading to quantitative immunoglobulin
determinations that show an IgG of 2,600 mg/dL, with
normal concentrations of IgA and IgM. Evaluation of a
bone marrow sample indicates that it is normocellular for
age, with 7% plasma cells and Congo red staining is negative. Compression fractures of vertebral bodies are seen
on x-ray but no lytic lesions are seen.
Which of the following is the most likely diagnosis?
A. Waldenstrms macroglobulinemia
B. Multiple myeloma
C. Monoclonal gammopathy of undetermined significance
D. Amyloidosis

58. Steroid hormones bind to receptors that are

transcription factors and activate the expression of
hormone-responsive genes.
Which of the following statements about steroid
response in cancer treatment is false?
A. Expression of the estrogen receptor is associated with
response to hormone therapy
B. Expression of the progesterone receptor is associated with
response to megestrol acetate
C. The t(15;17) translocation in acute promyelocytic
leukemia (APL) predicts for effectiveness of all-trans
retinoic acid
D. The level of expression of the androgen receptor does not
predict the efficacy of androgen ablation in prostate cancer
E. For advanced hormone-refractory prostate cancer, expression of the androgen receptor is often increased because
of gene amplification

59. Severe diarrhea developed in a 72-year-old patient

with rectal cancer, two weeks after treatment with an initial course of continuous infusion of fluorouracil and
pelvic radiation, given postoperatively because of the
risk of local-regional recurrence. Treatment for the diarrhea is begun with loperamide 2 mg for every loose
stool, to a total dose of 20 mg daily.
Despite this treatment, diarrhea continues to be a substantial problem, with 10 watery stools daily. The patient
is otherwise in good condition and is ingesting adequate
liquids to maintain normal hydration.
Which of the following medications would you recommend to alleviate this treatment-induced diarrhea?

A. Octreotide
B. Sucralfate
C. Ozalazine
D. Glutamine

60. A 30-year-old woman is referred by her primary

care physician for evaluation of bilateral lung nodules.
Five years ago, she had total thyroidectomy for a 2.5centimeter papillary thyroid cancer and subsequent
ablation of residual thyroid tissue with radioactive
iodine. She has had no subsequent treatment and was
lost to follow-up. Two weeks ago, she presented to her
primary care physician with nasal congestion and a
cough. A chest x-ray showed small bilateral pulmonary
nodules, which were confirmed by CT of the chest with
intravenous contrast. The serum thyroglobulin level
was elevated (227 ng/mL). The results of thoracoscopic biopsy of two nodules demonstrated papillary
histology. A diagnostic whole body scan with injection
of radioactive iodine, after recombinant thyrotropin

stimulation, revealed no evidence of iodine-avid

Currently, she is asymptomatic. Her only medication is
thyroxine. On physical examination, she appears healthy
and in no distress. Examination of the neck shows a
well-healed surgical scar with no palpable nodules and
no lymphadenopathy. The lung fields are clear to auscultation and percussion. The remainder of the examination is unremarkable.
Which of the following is the most appropriate management?
A. Chemotherapy with a doxorubicin-based regimen
B. Repeat whole body scan with injection of radioactive
iodine in six to eight weeks
C. Surgical resection of the dominant pulmonary nodule
D. External beam radiation therapy to the dominant pulmonary
E. Octreotide scan and treatment with somatostatin if the scan
is positive for disease

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