UNIVERSITY OF THE PHILIPPINES MANILA

PHILIPPINE GENERAL HOSPITAL

DEPARTMENT OF MEDICINE

MEDICAL ONCOLOGY
MONTHLY RESIDENTS’ EXAM
August 23, 2017

MULTIPLE CHOICE. Choose the BEST answer. On the scantron, shade the corresponding letter. Good luck!

1. The most pervasive and threatening concern among patients with cancer is the ever-present fear of relapse.
What is this called? (HPIM 19, c99, p475)
A. Cotard’s syndrome
B. Damocles syndrome
C. Demosthenes syndrome
D. Klüver-Bucy syndrome

2. Cancer and its treatment may lead to a decrease in nutrient intake to cause weight loss. Nutrition therapy is
important because cancer therapy is more toxic and less effective in the face of malnutrition. Nutritional
intervention is indicated in which of the following parameters? (HPIM 19, c99, p474)
A. Serum transferrin level 1500 mg/L
B. Serum albumin 31 g/L
C. Unexplained loss of 10kg BW
D. Poor appetite

3. You are trying to convince your brother to stop smoking. He rationalizes that he only smokes half a pack of
cigarettes per day and has only been smoking for 10 years so his risk is not so high. Which of the following
statements are TRUE of the benefits of smoking cessation? (HPIM 19, c100, p475)
A. Those who stop smoking have a 30-50% lower 10-year lung cancer mortality rate.
B. Switching to light and low-tar cigarettes will decrease risk of lung cancer.
C. Smokeless tobacco is another alternative with less carcinogenic effects.
D. Lessening cigarette use is a successful strategy to quit smoking.

4. Which of the following dietary strategies reduce the risk of cancer? (HPIM 19, c100, p476)
A. Low fat diet
B. High fiber diet
C. Calcium/vitamin D supplementation
D. None of the above

5. Which of the following chemoprevention strategies reduce the risk of cancer? (HPIM 19, c100, p477)
A. Beta-Carotene and Retinol in workers with asbestos exposure
B. Cyclooxygenase-2 inhibitors for colorectal cancer
C. Raloxifene in postmenopausal women
D. Alpha tocopherol for prostate cancer

6. Your 60-year-old mother underwent an “executive check-up” at a fancy tertiary hospital in the city. She shows
you her results – all of which are normal – including a CT colonography result. She asks you if this test is a good
screening test and when she needs to repeat the screening. What is the most appropriate advice to give?
(HPIM 19, c100, p481)
A. Perform colonoscopy now and repeat every ten years.
B. Send for fecal immunochemical testing to strengthen the findings of the colonography.
C. Perform sigmoidoscopy now and every 5 years.
D. Repeat CT colonography in 5 years.

7. The critical element in growth of primary tumors is the angiogenic switch. Which of the following stimulates
tumor angiogenesis? (HPIM 19, c102e-13)
A. Radiation
B. Hemolysis
C. Anemia
D. Inflammation

8. The general internist should make sure that a patient’s cancer biopsy is appropriately sent for important
molecular studies. Which of the following special studies are matched correctly? (HPIM 19, c103e-1)
A. Breast cancer: B-raf oncoprotein mutation
B. Colon cancer: c-kit oncoprotein mutation
C. Melanoma: c-kit expression and mutation
D. Lung cancer, squamous cell: B-raf oncoprotein mutation
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9. Which of the following advanced cancers can possibly be cured with chemotherapy and radiation? (HPIM 19,
c103e-3)
A. Squamous carcinoma of the head and neck
B. Endometrial sarcoma
C. Biliary tract neoplasm
D. Prostate cancer
10. There are multiple modalities to treat cancer each of which carries its own toxicity. Which of the following
parts of the body are the most sensitive to radiation therapy? (HPIM 19, c103e-4)
A. Bone
B. Ovary
C. Vascular endothelium
D. Mucosal lining of the intestinal tract

11. The most common side effect of chemotherapy is nausea. In a patient receiving cisplatin & paclitaxel for lung
cancer, which of the following drugs will be LEAST useful to deal with the nausea? (HPIM 19, c103e-25)
A. Ondansetron
B. Aprepitant
C. Dexamethasone
D. Prochlorperazine

12. Cancers such as chronic lymphocytic leukemia and multiple myeloma weaken one’s humoral immunity,
specifically with a lack of antibody. Which of the following organisms should be considered first when there is
a suspected infection in these patients? (HPIM 19, c104, p484)
A. Streptococcus pneumoniae
B. Enteric organisms
C. Fungi
D. Herpesvirus

13. Which of the following is NOT an effective antibiotic regimen for the treatment of febrile patients with
prolonged neutropenia? (HPIM 19, c104, p491)
A. Cefepime
B. Piperacillin tazobactam
C. Imipenem/cilastatin
D. Vancomycin

14. A 62-year-old male is evaluated for a 1-month history of nausea, anorexia, right upper quadrant abdominal
pain, and a 4.5-kg weight loss. A superficial spreading melanoma of the left thigh, 2.2 mm deep, with one
positive sentinel lymph node was diagnosed 1 year ago. The patient declined adjuvant interferon alfa therapy.
PE reveals mild right upper quadrant tenderness to palpation, and the liver is palpable 4 cm below the
costochondral margin with a nodular, firm edge. CT scan of the abdomen and pelvis shows an enlarged liver
with five hypodense lesions in both lobes measuring up to 2.5 cm that are consistent with metastases. Which
of the following is the most appropriate next step in management? (HPIM 19, c105, p499)
A. BRAF V600 mutation analysis
B. Dacarbazine-based chemotherapy
C. High-dose interferon alfa
D. Immunotherapy with ipilimumab

15. A 62-year-old male is admitted for a 6-week history of progressive cough, hemoptysis, and shortness of
breath. Prior to the onset of symptoms, he reports feeling well except for some difficulty rising out of a chair
and walking up a flight of stairs because of lower extremity weakness. He is a 50-pack-year smoker. On PE, BP
140/80, HR 102, RR 14, T 37.6, O2Sat 90% on room air. Chest and cardiac PE are unremarkable. On neuro PE,
he has symmetric proximal muscle weakness in both his upper and lower extremities. There is no palpable
peripheral lymphadenopathy. Chest x-ray shows a right hilar mass. CT confirms an 8-cm right hilar mass
adjacent to the mediastinum with bilateral mediastinal lymphadenopathy. Which of the following is the most
likely diagnosis? (HPIM 19, c107, p511-512)
A. Small cell lung cancer
B. Squamous cell carcinoma of the lung
C. Adenocarcinoma of the lung
D. Atypical bronchial carcinoid tumor

16. Low dose noncontrast, thin-slice spiral chest CT scan has emerged as an effective tool to screen for lung
cancer. Which of the following should be considered even when performing the test on high-risk patients?
(HPIM 19, c107, p510)
A. High false-negative results
B. Low false-positive results
C. Limitation of future follow-up visits if negative
D. Potential for underdiagnosis
MEDICAL ONCOLOGY EXAM | JACL 2017 2
17. A 64-year-old male is evaluated for left-sided pleuritic chest pain. The discomfort is localized to the upper left
chest and supraclavicular region. He is a 35-pack-year smoker. On PE, BP 130/70, HR 68, RR 12. There are
multiple firm, nonmobile lymph nodes in the left supraclavicular space. The lungs are clear. A plain chest
radiograph shows a left upper lobe opacity, bilateral hilar lymphadenopathy. CT scan reveals a left apical mass.
Which of the following is the most appropriate diagnostic test to perform next? (HPIM 19, c107, p512)
A. Bronchoscopy with needle aspiration of mediastinal lymph nodes
B. Bronchoscopy with transbronchial biopsy of the left apical mass
C. CT-guided biopsy of the left apical mass
D. Needle aspiration of the left supraclavicular lymph nodes

18. A 55-year-old male is evaluated for a 3-month history of cough and unexplained weight loss and a 2-week
history of shortness of breath. He is a non-smoker. On PE, VS are normal, breath sounds are decreased, and
there is dullness to percussion over the right lung field. Chest x-ray shows a right pleural effusion and right
hilar mass. CT scan of the chest reveals a large right pleural effusion, a right upper lobe mass with associated
consolidation, hilar and mediastinal lymphadenopathy, and an irregular right adrenal mass. A CT-guided
transthoracic biopsy of the right upper lobe mass shows adenocarcinoma. Which of the following is the most
appropriate management? (HPIM 19, c107, p521)
A. EGFR mutation testing
B. K-ras mutation testing
C. PET scanning
D. Surgical resection

19. Which of the following IHC results would suggest an adenocarcinoma of the lung? (HPIM 19, c107, p508)
A. TTF-1 positive
B. TTF -1 Negative
C. p63 positive
D. p63 negative

20. Which of the following is particularly associated with an increased risk of breast cancer in younger women?
(HPIM 19, c108, p524)
A. Increased total caloric intake
B. Increased fat intake
C. Radiation
D. Use of conjugated estrogens alone

21. A 35-year-old female came to your clinic due to a 6-month history of a persistent breast mass. On physical
examination, you palpated a solid mass on the left breast measuring 1.7 cm x 1.9 cm with no associated skin
changes or axillary lymphadenopathies. She is currently on her period. She also informed you that she has no
family history of cancer. Which of the following is the most appropriate next step? (HPIM 19, c108, p525)
A. Reexamine the patient in 2-4 weeks, during the follicular phase of her menstrual cycle.
B. Order a mammogram to further characterize the mass noninvasively.
C. Order a fine-needle aspiration biopsy.
D. Order an incision or excision biopsy.

22. A screening mammography performed on a 46-year-old female showed clustered microcalcifications on the
right breast. However, there is no palpable breast mass on physical examination. On history, she had no
significant risk factors for developing breast cancer. Which of the following is the most appropriate next step?
(HPIM 19, c108, p525-526)
A. Order a repeat routine mammography.
B. Order a breast ultrasound.
C. Perform routine follow-up appropriate to the patient’s age.
D. Perform mammographic follow-up in 3-6 months.

23. A 43-year-old female is in the clinic for follow-up after a recent diagnosis of estrogen receptor–positive,
progesterone receptor–positive, HER2-negative, grade 2 invasive ductal CA of the left breast. The patient was
treated with surgery, adjuvant chemotherapy, and radiation. This is her first postradiation visit. She is
premenopausal. On PE, VS are normal. There are well-healed incisions of the left breast and left axilla. There is
no LAD and no right breast masses. CBC and serum chemistry are normal. Which of the following is the most
appropriate therapy? (HPIM 19, c108, p529)
A. Exemestane alone
B. Tamoxifen alone
C. Maintenance chemotherapy with oral capecitabine
D. No additional adjuvant therapy

24. What is the most common site of gastric cancer metastasis? (HPIM 19, c109, p534; Actual PSBIM 2017
Question)
A. Lung
MEDICAL ONCOLOGY EXAM | JACL 2017 3
 B. Liver
C. Ovary
D. Peritoneal cul-de-sac
25. The long-term ingestion of high concentrations of nitrates found in dried, smoked and salted foods appears to
be associated with higher risk of gastric adenocarcinoma. The hypothesis that explains this carcinogenic effect
of dietary nitrates is: (HPIM 19, c109, p534)
A. Dietary nitrates cause ulceration and direct inflammation resulting to dysplasia
B. Dietary nitrates are converted to carcinogenic nitrites by bacteria
C. Dietary nitrates result to overgrowth of Helicobacter pylori which is directly related to carcinogenesis
D. Dietary nitrates influence gene overexpression of HER2/neu gene that results to dysplasia

26. A 62-year-old male is evaluated for a 4- to 6-week history of passing bright red blood stool. On PE, VS are
normal; abdominal PE is normal. DRE reveals brown stool that is positive for occult blood. Colonoscopy reveals
a nonobstructing polypoid mass in the sigmoid colon. The remainder of the colon, from the ileocecal valve to
the anus, is normal. Biopsy of the mass shows adenocarcinoma. Which of the following diagnostic studies
should be performed next? (HPIM 19, c110, p542)
A. Bone scan
B. CT of the chest, abdomen, and pelvis
C. CT colonography
D. PET/CT

27. A 58-year-old male undergoes follow-up evaluation for cancer of the ascending colon diagnosed 3 weeks ago.
Colonoscopy at that time revealed a fungating mass in the ascending colon. Biopsy revealed adenocarcinoma,
and additional studies showed no evidence of metastatic disease. Right hemicolectomy was performed. The
pathology report showed a 4-cm primary adenocarcinoma with clear margins at resection, full-thickness
penetration through the colonic wall into pericolonic fat, and 4/21 lymph nodes involved (stage III). PE is
normal. Which of the following is the most appropriate management at this time? (HPIM 19, c110, p543)
A. Leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX)
B. Radiation therapy and capecitabine followed by capecitabine plus oxaliplatin (CAPOX)
C. Radiation therapy
D. Observation

28. Depending on the location of the malignancy/tumor, a patient may present with various symptoms. What
possible location in the colon would you expect the tumor be for a patient presenting with abdominal
cramping, obstruction and perforation? (HPIM 19, c109, p541)
A. Cecum
B. Ascending colon
C. Descending colon
D. Rectosigmoid

29. A 30-year-old male presented with colorectal cancer. He also a paternal family history of colon cancer.
Suspecting an underlying polyposis syndrome at play, genetic testing confirmed that the patient has germline
Turcot’s syndrome. His two children age 10 and 15 should be monitored for polyposis and what other tumor?
(HPIM 19, c110, p538-539)
A. Medullary Thyroid CA
B. Medulloblastoma
C. WIlm’s Tumor
D. Rhabdomyosarcoma

30. For which stages of hepatocellular carcinoma can curative treatments be offered to patients? (HPIM 19, c111,
p546)
A. Stage 0
B. Stage B
C. Stage D
D. Stage 4

31. A 55-year-old male is evaluated for a 1-year history of postprandial indigestion associated with nausea, oily
stools, and a 4.5-kg weight loss over the past 6 months. He has prediabetes and currently takes ibuprofen and
omeprazole. On PE, VS are normal; he has icteric sclerae. Abdominal PE reveals epigastric pain without
guarding or rebound. Upper endoscopy is normal. CT scan with contrast shows a solid 2.5-cm hypoattenuating
lesion suspicious for pancreatic adenocarcinoma confined to the head of the pancreas. Dilation of the
upstream pancreatic duct and common bile duct is noted. There is no regional lymphadenopathy. The liver
parenchyma appears normal. Which of the following is the most appropriate management? (HPIM 19, c113,
p555)
A. Endoscopic ultrasound-guided FNAB
B. Measurement of CA 19-9
C. Percutaneous needle biopsy
D. Surgical resection of the pancreatic mass
MEDICAL ONCOLOGY EXAM | JACL 2017 4
32. A 70-year-old male presents with hematuria, abdominal pain, and weight loss. On work-up, abdominal CT scan
reveals a solid mass on the upper pole of the left kidney measuring 4cm. Laboratories reveal Hemoglobin 100
g/L, Calcium of 2.9 mmol/L, urinalysis +3 blood with 100% dysmorphic RBCs. Chest CT scan is clear of
suspected metastasis. Which of the following is the most appropriate management? (HPIM 19, c114, p578)
A. Surgical resection
B. Interferon alpha
C. Sorafenib
D. Everolimus

33. A 68-year-old man requests evaluation for prostate cancer. He is asymptomatic. Following a discussion of the
risks and benefits of prostate cancer screening, the patient decides to be screened. PE is normal, DRE is
normal. PSA is 13 ug/L (high). Transrectal ultrasound–guided prostate biopsy is done and was negative in all 12
specimens. Which of the following is the most appropriate next step in management? (HPIM 19, c115, p581)
A. Repeat serum PSA
B. Close follow-up with possible repeat biopsy
C. Reassurance
D. Observation

34. A 78-year-old male is evaluated for headaches, blurred vision, facial flushing, and mild right midback
discomfort. He is a nonsmoker. On PE, BP 150/90, O2Sat 99%, (+) facial plethora. There is no
hepatosplenomegaly. Laboratories reveal the following: Erythropoietin 150 U/L, Hematocrit 55.2%,
Hemoglobin 182 g/L, WBC 8200/uL, Platelet 312,000/uL, Urinalysis shows microscopic hematuria. Which of
the following diagnostic studies should be performed next? (HPIM 19, c121, p612)
A. Bone marrow biopsy
B. CT of the abdomen and pelvis
C. JAK2 mutation testing
D. Peripheral blood flow cytometry

35. Which of the following chemotherapeutic drugs cause proven cardiotoxicity? (HPIM 19, c125, p621)
A. Cisplatin
B. Nilotinib
C. Trastuzumab
D. Cyclophosphamide

36. Your patient since 1st year visits you in the OPD and inquires about whole brain irradiation for her brain
metastasis. She is a 50-year-old previous accountant who enjoys completing Sudoku and crossword puzzles.
Which of the following longterm effects is found in radiation therapy of the neurologic system? (HPIM 19,
c125, p622)
A. Cognitive decline
B. Nausea and hypersomnia
C. Leukoencephalopathy
D. Glove and stocking neuropathy

37. A 72-year-old male is in the ER for a 3-week history of headache and facial swelling and a 2-week history of
shortness of breath. On PE, HR 104, RR 22, O2Sat 90% on room air. Diffuse facial erythema is present, and
neck veins are dilated bilaterally. CT scan of the chest shows a 7-cm medial left lung mass and bulky
mediastinal lymphadenopathy. Superior vena cava compression with associated collateral vessels is also
identified. Which of the following is the most appropriate management? (HPIM 19, c331, p1788)
A. Biopsy of the lung mass
B. Immediate radiation therapy
C. Placement of a superior vena cava stent
D. Venography

38. Superior vena cava syndrome is the clinical manifestation of SVC obstruction, with severe reduction in venous
return from the head, neck, and upper extremities. Which cancer type accounts for the majority (~85%) of all
cases of SVC syndrome with a malignant origin? (HPIM 19, c331, p1787)
A. Lung cancer
B. Lymphoma
C. Thymic cancer
D. Metastatic cancer to the mediastinum

MEDICAL ONCOLOGY EXAM | JACL 2017 5

39. A 78-year-old male is admitted for a 1-week history of progressive and severe back pain and weakness in both
legs. He describes a sense of “heaviness” in his legs and has had increasing difficulty climbing stairs and getting
out of a chair. He has asymptomatic multiple myeloma that has been followed with periodic examinations and
laboratory studies; his last assessment was 3 months ago and was stable. On PE, there is point tenderness
over the T10 and T11 vertebral bodies, decreased lower extremity muscle strength (3+/5), increased reflexes
isolated to both lower extremities, and bilateral extensor plantar responses. Hemoglobin is 65 g/L and serum
calcium is 3.2 mmol/L. MRI of the thoracic and lumbar spine shows a vertebral body mass with extension into
the epidural space at T12 and compression of the spinal cord. Which of the following is the most appropriate
initial step in treatment? (HPIM 19, c331, p1791)
A. Decompressive surgery
B. Intravenous glucocorticoids
C. Multiagent chemotherapy
D. Radiation therapy

40. A 27-year-old male is evaluated in the ER for a 1-week history of bruising and gingival bleeding with flossing.
On PE, BP 110/80, HR 80, RR 14, T 37.5. There are scattered ecchymoses and cutaneous petechiae present.
There is no lymphadenopathy or splenomegaly. Labs are as follows: WBC 150,000/uL, Platelet 20,000/uL,
Creatinine 353 umol/L, Fibrinogen Normal, Phosphorus 8 mg/dL (N: 2.5-4.5 mg/dL), Uric Acid 12 mg/dL (N: 3.4-
7.0 mg/dL). Peripheral blood smear shows 70% circulating myeloblasts. Which of the following is the most
appropriate treatment? (HPIM 19, c331, p1795)
A. Fresh frozen plasma
B. High volume normal saline hydration and rasburicase
C. Multiagent chemotherapy
D. Platelet transfusion

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