Download Q1. A 58 year women was referred to the gastroenterology clinic

Q1.
A 58 year women was referred to the gastroenterology clinic with a history of weight loss.
Clinical examination including a breast and rectal examination was normal. A CT scan of the
chest, abdomen and pelvis revealed enlarged right axillary lymph nodes only. Excision
biopsy of the lymph node revealed adenocarcinoma. The case is being discussed in the
cancer MDT. What is the most appropriate next step?
a. Mammogram
b. Tumour markers
c. PET scan
d. Oncology referral
e. Colonoscopy
Answer: a
These patients with axillary lymph node metastasis of adenocarcinoma should undergo
mammography or breast MRI. Immunohistology for hormone status and c-erb2 should also
be checked. These patients with compatible immunohistology (even in the absence of a
breast primary) should be treated as breast cancer with lymph node involvement (stage II)
This is a cancer with unknown primary (CUP). The median survival of patients with the CUP
syndrome is 3 to 6 months. However, certain subgroups of CUP have a good prognosis.
Axillary lymph node metastasis of adenocarcinoma in a woman is a CUP with good
prognosis.
Q2.
A 50 year old man with PSC presented with obstructive jaundice. A CT scan raised the
possibility of cholangiocarcinoma. The following are true except:
a. ERCP and brush cytology usually yield the diagnosis
b. PSC is the commonest predisposing factor for cholangiocarcinoma in the western
world.
c. The risk of developing cholangiocarcinoma is not associated with the duration of
PSC.
d. Cholangiocarcinoma is often associated with intermittent rather than steadily
progressive jaundice.
e. PET may be used is in screening patients with PSC for the presence of
cholangiocarcinoma.
Answer: a
Tissue diagnosis of cholangiocarcinoma is difficult because it is highly desmoplastic tumour
composed of a few malignant cholangiocytes within excessive fibrous tissue. Thus cytology
is positive in only 1/3rd of cases.
Q3.
A 70 year old man presents with painless obstructive jaundice. A CT scan is suspicious for
tumour involving common hepatic duct bifurcation (Klatskin tumour). The following
statements are true except:
a.
b.
c.
d.
e.
A raised Ca19-9 is diagnostic
Distant metastases are distinctly uncommon in cholangiocarcinoma.
Majority of cholangiocarcinoma are adenocarcinoma
Laparoscopy should be standard before resection
Biliary stents are often placed prior to surgery
Answer: a
A raised Ca19-9 is suggestive but not diagnostic. Laparoscopy will identify 25-30% of
patients as unresectable who were thought to be operable before laparoscopy. Therefore
laparoscopy should be standard before operation.
Many surgeons proceed directly to laparotomy without preoperative biliary drainage. On the
other hand, there is often uncertainty as to resectability as well as the timetable of surgical
evaluation and operative management in patients presenting with jaundice. As a practical
issue, stents are often placed to alleviate jaundice while these issues are being settled.
Q4.
A 75 year old man presented with bleeding PR. A colonoscopy revealed a rectal
adenocarcinoma at 10 cms from the dentate line. All the following tests are indicated except:
a.
b.
c.
d.
e.
Staging CT scan
MRI pelvis for local staging (nodes and depth of invasion)
EUS rectum can also be used for local staging and is cheaper than MRI
CEA
All of the above
Q5.
A 55 year old man is found to have isolated liver metastases at the time of primary surgery
for colon cancer. Choose the most appropriate answer?
a.
b.
c.
d.
e.
The liver metastases should be resected synchronously with colon cancer resection.
Liver biopsy should be obtained without liver resection
Liver resection is always done after adjuvant chemotherapy for colon cancer
Surgery for colon cancer should be abandoned as the cancer is now inoperable
None of the above
Answer: e
Normally, colorectal cancer resection & liver resection would not be performed
synchronously. Lesions discovered at operation should not be biopsied. Patients with
potentially resectable liver disease and who have undergone radical resection of the primary
tumour should be considered for liver resection before consideration of chemotherapy.
Patients with unfavourable primary pathology such as perforated primary tumour or
extensive nodal involvement should be considered for adjuvant chemotherapy prior to liver
resection and be restaged at three months.
It has been argued that the limiting factor to the number of lesions that can be resected is
whether it is technically possible to remove all tumours. Patients with solitary, multiple and
bilobar metastatic disease are candidates for liver resection. The surgeon should define the
acceptable residual functioning volume, approximately one third of the standard liver volume,
or the equivalent of a minimum of two segments.
Q6.
Please choose the most appropriate answer for colorectal cancers?
a. Right sided cancers commonly present with iron deficiency anaemia and left sided
tumours present with change in bowel habit
b. Streptococcus bovis bacteraemia and Clostridium septicum sepsis can be due to
underlying colonic malignancies.
c. Synchronous cancer occur in up to 5 percent of patients
d. Serum CEA has prognostic utility in patients with newly diagnosed colorectal cancer
e. All of the above
Answer: e
Synchronous CRCs are defined as two or more distinct primary tumors separated by normal
bowel and not due to direct extension or metastasis. It occurs in up to 5 percent of patients
with colon cancer.
American Society of Clinical Oncology (ASCO) guidelines recommend that serum CEA
levels be obtained preoperatively in patients with demonstrated colorectal cancer to aid in
staging, surgical treatment planning, and in the assessment of prognosis
Q7.
A 65 year old gentleman was found to have a cystic mass in the head of pancreas on a CT
scan done for abdominal pain. All of the following are true except:
a. Almost all cystic neoplasm’s of pancreas are symptomatic
b. The differential diagnosis includes serous cyst adenoma, mucinous cyst adenoma or
Intraductal papillary mucinous neoplasm (IPMN).
c. EUS and fluid aspirate analysis for CEA and amylase can be diagnostic
d. Serous cyst adenomas are nearly always benign and can be managed
conservatively
e. Mucinous cyst adenomas are benign but malignant transformation can occur and
hence resection should be considered.
Answer: a
50% of patients do not have any symptoms and are detected incidentally at imaging studies
performed for unrelated indications. Symptoms (abdominal pain and jaundice) when occur
are due to mass effect. It is conceptually useful to think of serous cyst adenoma to be like
hyperplastic polyps in colon and mucinous cyst adenoma to be like colonic adenomas.
Q8.
A 60 year old woman has been diagnosed with gall bladder cancer incidentally at
cholecystectomy. What are the risk factors for gall bladder cancer? Choose the most
appropriate answer
a.
b.
c.
d.
e.
Gallstones
Porcelain gallbladder
Gallbladder polyps
All of the above
b and c
Answer: d
Q9.
All the following are the risk factors for gastric cancer except one:
a.
b.
c.
d.
e.
Helicobacter pylori infection
Atrophic gastritis
Pernicious anaemia
Alcohol abuse
Smoking
Answer: d
Q10.
All the following investigations may be needed to stage gastric adenocarcinoma except one:
a.
b.
c.
d.
e.
Staging CT
Laparoscopy
Bone scan
EUS
Exploratory laparotomy
Answer: e
Laparoscopy is routinely used following CT and EUS in patients with T2 or greater gastric
cancer prior to radical treatment. It is also considered in any patients where there is
suspicion of peritoneal spread on CT or EUS such as in the presence of small volume
ascites. Patients with advanced disease (>T2N0) who have not undergone full body PET-CT
require a bone scan to exclude bony metastases.
Q11.
All the following are true about fundic gland polyp (FGP) except :
a.
b.
c.
d.
e.
Hamartomatous polyps
Associated with PPI use
Associated with FAP
Sporadic FGP are found exclusively in patients without H.Pylori infection
Usually more than 10 mm in size
Answer: e
FGP are smooth, glassy, sessile, circumscribed elevations (usually measuring < 5 mm).
Sporadic and PPI associated FGPs have low malignant potential and no ominous
associations. By contrast, a definite risk of dysplasia (between 30% and 50%) is present in
FAP associated FGPs. Thus FGP should be carefully biopsied in FAP. Dysplasia in FGPs is
also associated with large polyp size (>1 cm).
Q12.
A 55 year old man underwent an OGD for dyspepsia. It showed a 2 cms polyp in the gastric
antrum. It was excised and retrieved. The following is true about gastric polyps except:
a. Gastric polyps are mostly asymptomatic and are typically found incidentally at OGD
b. H. Pylori eradication causes regression of up to 70% of hyperplastic polyps.
c. Adenomatous gastric polyps are at increased risk for malignant change and should
be excised
d. Hyperplastic polyps have also a low but definite potential for development of
malignancy.
e. Surveillance endoscopy is indicated after removal of gastric polyps
Answer: e
The guidelines of the American Society of Gastrointestinal Endoscopy (ASGE) recommend
surveillance endoscopy one year after removing adenomatous gastric polyps to assess
recurrence at the prior excision site. Hyperplastic polyps have low malignant potential and
further surveillance endoscopy is not recommended after excision.
Q13.
A 46 year old man was found to have a subepithelial mass in the antrum at OGD. An
endoscopic evaluation of the mass includes all the following except:
a.
b.
c.
d.
Assessment for intramural mass vs. extrinsic compression
Estimating the size
Mobility and consistency
Biopsies
e. Margins
Answer: e
Assessment of intramural mass vs. extrinsic compression is facilitated by changing the
patient’s position to see if the location and appearance of the mass changes. Also, a change
in appearance of the mass with either air insufflation or deflation may help in determining if
the lesion is due to extrinsic compression. The size of the lesion is important in its
management. Endoscopic assessment of the size can be performed better with an open
biopsy forceps (which is 5mm in diameter). Mobility and consistency: A mobile mass that is
soft and indents when depressed using biopsy forceps (pillow sign) is highly suggestive of a
lipoma. A firm, minimally mobile lesion is suggestive of a GIST or leiomyoma.
It is reasonable to obtain mucosal biopsies to exclude epithelial polyps or lesions arising
from the deep mucosa. The yield of mucosal biopsies is low, however if the biopsies are
positive further investigations may not be warranted.
Q14.
A 60 year woman was found to have a subepithelial mass in the gastric body at OGD. All is
true about endoscopic evaluation of the mass except:
a. If the mass has a pillow sign and is yellow in appearance, it is probably a lipoma and
no further evaluation is necessary.
b. Subepithelial masses less than 1 cm in diameter are rarely of clinical significance and
can be left alone.
c. All other lesions larger than 1 cms should be evaluated further by EUS
d. Subepithelial mass with a central umbilication suggests heterotopic pancreatic tissue
e. Endoscopist can accurately assess intramural mass from extrinsic compression
Answer: e
It is difficult to assess the intramural or extramural nature of the subepithelial mass.
However, even when the endoscopist suspects an intramural lesion is present, the mass
may arise from outside the gastrointestinal wall in up to 30% of cases. Thus, CT may have a
role (where EUS is not available) in defining the origin and extent of extramural masses.
Subepithelial masses less than 1 cm in diameter are rarely, if ever, of clinical significance.
A repeat endoscopy in one year is reasonable for these small masses, and if the mass is
unchanged, then further follow-up evaluation may not be required if the patient remains
asymptomatic.
Q15.
The following is true about gastric subepithelial masses except:
a.
b.
c.
d.
e.
GIST is the most common cause
Lipomas are a rare cause
EUS is the investigation of choice
CT scan is required to distinguish intramural from extramural compression
EUS findings may be diagnostic without tissue sampling
Answer: d
EUS can differentiate intramural from extramural lesions. SO CT scan is not required unless
EUS is not available
Q16.
A 47 year old gentleman was found to have a subepithelial mass at OGD. A subsequent
EUS revealed a hypoechoic mass arising from the muscle layer. FNA of the lesion was
performed. Cytology and immunohistochemistry was diagnostic of a GIST. The following is
true about a GIST tumour except:
a.
b.
c.
d.
e.
Stomach is the commonest site for GIST
Any symptomatic GIST is potentially aggressive
GIST virtually never metastases to lungs
Imatinib (Gleevac) is the treatment of choice.
GIST almost uniformly express c-kit (CD117)
Answer: d
Surgery is the treatment of choice. Imatinib is used for advanced or metastatic disease.
GIST frequently metastases to liver, rarely to regional lymph nodes and virtually never to
lungs. Site of primary tumour- Stomach (50%), Small bowel (25%), Colon (10%),
Oesophagus (5%), Extra intestinal (7%).
Q17.
A 55 year old woman was found to have incidental gallstones and a 5 mm polyp on an
ultrasound scan. Choose the most appropriate management for the patient:
a.
b.
c.
d.
e.
Cholecystectomy should be offered
Surgery should only be offered if the polyp was more than 10 mm in size
The patient can be followed up by regular ultrasound scans
CT scan is needed before surgery
EUS should be considered
Answer: a
Patients who have gallbladder polyps and concomitant gallstones should undergo
cholecystectomy regardless of the polyp size or symptoms since gallstones are a risk factor
for gallbladder cancer in patients with gallbladder polyps. Cholecystectomy should also be
recommended for patients who have biliary colic. Polyps 10 to 20 mm in diameter should be
regarded as possibly malignant. Cancer of this size is usually an early stage cancer and
laparoscopic cholecystectomy with full thickness dissection is recommended. Polyps less
than 10 mm can be followed up by regular USS.
Q18.
A 55 year old man with established cirrhosis underwent a six monthly surveillance
ultrasound scan (USS). It showed a suspicious focal liver lesion. A subsequent contrast
enhanced CT scan of abdomen confirmed a 2.5 cms focal lesion in the liver. AFP was raised
at 200 ng/ml. A previous AFP and USS were normal 6 months earlier. What is the most
appropriate next step?
a. Ultrasound guided liver biopsy
b.
c.
d.
e.
PET scan
Liver transplant referral
Repeat scan in 6 weeks
Repeat AFP in 6 weeks
Answer- c
A raised AFP in a cirrhotic patient with a focal liver lesion confirms the diagnosis of
hepatocellular carcinoma and further investigation is only required to establish the most
appropriate therapy.
Biopsy of potentially operable lesions is avoided due to the risk of tumour seeding in the
needle tract, which occurs in 1–3%.
The only proven potentially curative therapy for HCC remains surgical, either hepatic
resection or liver transplantation. Liver transplantation should be considered in any patient
with cirrhosis and HCC.
Q19.
A 60 year old man with established cirrhosis had a surveillance ultrasound scan (USS). It
showed a 2 cms focal liver lesion. AFP levels were normal. What is the most appropriate
next step?
a.
b.
c.
d.
e.
Repeat AFP at 6 weeks
Ultrasound guided liver biopsy
Repeat USS at 6 weeks
Contrast enhanced CT scan
Liver transplant referral
Answer: d
If AFP is normal, further radiological imaging (CT/MRI) usually allow a confident diagnosis of
HCC to be made and proceed to assessment of treatment without the need for biopsy.
The normal range for AFP is 10–20 ng/ml and a level >400 ng/ml is usually regarded as
diagnostic. However, up to 20% of HCC do not produce AFP, even when very large. A rising
AFP over time, even if the level does not reach 400 ng/ml, is virtually diagnostic of HCC.
Q20.
Surveillance for HCC is recommended in high risk patients with cirrhosis. All the following
patients are considered to be high risk except one:
a.
b.
c.
d.
e.
Males and females with established cirrhosis due to hepatitis B or C
Males and females with established cirrhosis due to genetic haemochromatosis
Males with alcohol related cirrhosis.
Males with cirrhosis due to primary biliary cirrhosis
Males and females with cirrhosis due to primary sclerosing cholangitis
Answer: e
The risk of HCC development in cirrhosis due to autoimmune hepatitis, primary sclerosing
cholangitis in both sexes, and alcoholic and primary biliary cirrhosis in women is generally
low. HCC in Wilson’s disease is well described despite adequate copper chelating therapy,
although the true incidence is difficult to establish. Non-cirrhotic HCCs do occur in viral
cirrhosis but the absolute risk is low.
If surveillance is offered, it should be six monthly abdominal ultrasound assessments in
combination with serum AFP estimation. This is based on estimated median doubling time of
6 months for HCC.
Q21.
A 40 year old Chinese man with cirrhosis due to hepatitis C is worried about the risk of
hepatocellular cancer (HCC) after reading a newspaper report. He seeks an earlier
outpatient appointment to discuss the risks. The risk of HCC in him is:
a. 0.1% per year
b. 1 % per year
c. 3-5% per year
d. 7-9% per year
e. > 10% per year
Answer: c
There is a considerable variation in the risk of HCC development in cirrhosis of different
aetiologies. Cirrhosis due to hepatitis B or C carries a higher risk (3-5% per year). Patients
with cirrhosis due to genetic haemochromatosis who were iron loaded at presentation had a
very high risk of HCC development (7–9% per year). The risk falls with venesection but not
to baseline levels (1–3% per year). Alcoholic cirrhosis carries an increased risk of HCC
development (1-4% per year for males).
Q22.
A 63 year old gentleman underwent OGD for abdominal pain. It showed an ulcer in the
antrum. The biopsies taken from the ulcer confirmed a MALToma. Staging for MALToma
includes all except:
a.
b.
c.
d.
e.
Staging CT
Bone marrow aspiration
EUS
LDH, B2 microglobulin
Laparoscopy
Answer: e
All patients diagnosed with MALToma should have the following tests done:


Baseline bloods-LDH, B2 microglobulin
OGD- with multiple biopsies from all the visible lesions & the non-involved areas with
complete mapping of the organ



Staging CT
Bone marrow biopsy
EUS- for evaluation of depth of invasion and presence of perigastric lymph nodes
Regardless of the presentation site- all the above diagnostic studies should be done.
Q23.
The following is true about MALToma except:
a.
b.
c.
d.
e.
Most common primary GI lymphoma worldwide
Stomach is the commonest site of MALToma
Gastric MALToma is caused by H. Pylori infection
Prognosis is generally good
Surgery is the treatment of choice for gastric MALToma
Answer: e
Surgery was once the cornerstone, but the role is limited at present. As MALToma is a
multifocal disease, a total gastrectomy will be needed. This is associated with significant
morbidity. H. Pylori infection has been definitively established as a cause of MALTomas.
90% of MALToma patients are infected with H. Pylori.
Q24.
Gastric MALTomas generally have a good prognosis. The following is true about the
treatment of gastric MALTomas except:
a. H. Pylori eradication may be sufficient treatment in H. Pylori positive localised
disease
b. Chemotherapy or radiotherapy can be successfully used for failed antibiotic
treatment, H. Pylori negative or extensive disease
c. Regular surveillance OGD is needed to monitor response and recurrence
d. Prognosis is fairly good
e. MALToma is a focal disease
Answer: e
Gastric MALToma is a multifocal disease. Thus surgery is no longer used as the primary
treatment as total gastrectomy will be needed. This has high morbidity.
Q25.
A 55 year old man had an endoscopy performed for abdominal pain and dyspepsia. It showed a
nodule with a yellowish tinge in the proximal greater curve.
The biopsies confirmed it to be a neuroendocrine tumour. The most appropriate next step is:
a. EUS
b. Urine HIAA
c. Staging CT scan
d. PET scan
e. Gut hormone profile
Answer: c
Neuroendocrine tumours express somatostatin receptors (SSTR) and this has led to the
development of radio labelled somatostatin analogues for diagnostic imaging. SSRS
(somatostatin receptor scan or octreoscan) is the diagnostic test of choice to locate
secondaries. SSRS prior to surgery revised the staging and changed management in 33% in
Krenning’s series
Q26.
A 55 year old has been diagnosed with metastatic oesophageal adenocarcinoma. You are
due to see him in your gastroenterology clinic and refer him to oncology if appropriate. How
is fitness for chemotherapy commonly assessed?
a. ASA classification of physical status
b. Groningen fitness test
c. WHO performance status
d. Echocardiogram
e. 6- minute walk test
Answer: c
Fitness for chemotherapy is generally assessed by using The World Health Organisation
performance scale. It has categories from 0 to 4.
0 - Fully active patient
1 - Cannot carry out heavy physical work, but can do anything else.
2 - Up and about more than half the day; can look after himself, but not well enough to work.
3 - In bed or sitting in a chair for more than half the day; need some help in looking after him
4 - In bed or a chair all the time and need a lot of looking after
Generally patients are considered fit for chemotherapy with good performance status (PS0,
PS1). Good PS2 (leaning towards PS1) are also generally considered fit for chemotherapy
Q27.
A 55 year old has been diagnosed with oesophageal adenocarcinoma. You are due to see
him in your gastroenterology clinic and refer him to an upper GI surgeon for curative surgery,
if appropriate. How is fitness for surgery commonly assessed?
a. ASA classification of physical status
b. Groningen fitness test
c. WHO performance status
d. Echocardiogram
e. 6- minute walk test
Answer: a
The previous medical history and concurrent morbidity remain the strongest predictors
regarding fitness for surgery. The American Society of Anaesthesiologists (ASA)
classification of physical status is well recognised. Perioperative risk increases with
increasing ASA score. Only those patients with an ASA score of 3 or less should be
considered for surgery.
Q28:
A 70 year old man has been diagnosed with adenocarcinoma of the lower thoracic
oesophagus. A staging CT scan revealed coeliac lymph node involvement with no distant
metastases. He is managing to eat and drink normally currently. What is the most
appropriate treatment?
a. Curative surgery
b. Radical radiotherapy
c. Palliative chemotherapy
d. Oesophageal stent
e. EMR
Answer: c
Thoracic oesophagus drains in posterior mediastinal nodes. Involvement of coeliac nodes in
lower thoracic tumour makes it M1 (i.e. stage IV) disease and hence incurable. Endoscopic
palliation (stent) is only needed in presence of dysphagic symptoms.
Q29.
The risk factors for pancreatic cancer includes all except:
a.
b.
c.
d.
e.
Diabetes mellitus
Hereditary predisposition
Chronic pancreatitis
Smoking
Acute pancreatitis
Answer: e
Q30.
The differential diagnosis of a mass lesion in pancreas includes all except:
a.
b.
c.
d.
e.
Lymphoma
Neuroendocrine tumour
Focal chronic pancreatitis
Autoimmune pancreatitis
None of the above
Answer: e
Q31.
A 65 year old gentleman presented with dull aching upper abdominal pain radiating through
to the back and worsened by eating. He had also noticed yellow discoloration of his skin and
had lost weight. In his past medical history, he was diagnosed with diabetes mellitus 6
months earlier. A CT scan revealed a localised mass lesion in the head of pancreas with
biliary duct dilatation.
All the following are true except:
a. CT guided biopsy is needed to confirm the diagnosis
b. There is little evidence of benefit from routine biliary stenting of jaundiced patients
before resection.
c. A diagnosis of pancreatic cancer should be considered in unexplained diabetes (no
family history, obesity or steroids) in patients over 50 years of age.
d. Gastroduodenal artery encasement is not a contraindication for curative surgery
e. Whipple’s operation is the standard operation for cancer of pancreatic head
Answer: a
EUS guided FNA biopsy is used in patients with resectable tumours. This is less likely to
cause intraperitoneal spread of the tumor since the biopsy is obtained through the bowel wall
rather than percutaneously.
Biliary stenting may be helpful if the surgery is delayed for more than 10 days as patients
with obstructive jaundice are at risk for associated coagulopathy, malabsorption, and
malnutrition.
Q32.
A 69 year old man underwent a screening colonoscopy under National bowel cancer
screening programme. A 1.5 pedunculated polyp in the sigmoid colon was excised and
retrieved. The histology report details the polyp as a well differentiated adenocarcinoma with
clear margins and no evidence of lymphovascular invasion and Haggitt level 2. Choose the
most appropriate answer?
a. Cancerous polyps are classified according to Haggitt level
b. Polyps classified as Haggitt level 3 or lower have a less than 1% likelihood of lymph
node metastasis
c. Decision to proceed to surgical resection needs to be individualized
d. Haggitt level 4 polyps have a 12-25% risk of lymph node metastasis and should be
treated with segmental colectomy
e. All of the above
Answer: e
Cancerous polyps are classified according to Haggitt level:
Level 0- carcinoma in situ
Level 1- submucosa in the head of the polyp
Level 2- submucosa in the neck of the polyp
Level 3- submucosa in the stalk of the polyp
Level 4- submucosa beyond the stalk
Polyps classified as Haggitt level 3 or lower have a less than 1% likelihood of lymph node
metastasis and can be treated with polypectomy alone when they meet the following
pathologic criteria: specimen margins are greater than 2 mm, no evidence of lymphovascular
invasion and the tumour is well differentiated