Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3981_Библиотеки_им_академика_М_И_Перельмана.pdf
Thoracic Surgery: Questions
49
C. It is predominantly seen in the elderly population.
D. It is typically diagnosed by conventional radiography.
E. It typically arises from the large airways.
3.26 Mucoepidermoid carcinoma of the bronchus is a rare primary lung
malignancy. It is
A. characterized by reduced production of mucoepidermoid carcinoma translocated 1–
mastermind-like 2 (MECT1-MAML2).
B. differentiated from adenocarcinoma by immunoperoxidase staining with antibodies to
cytokeratin 7 and thyroid transcription factor 1.
C. not known to recur once completely excised.
D. predominantly caused by reciprocal translocation involving chromosome X.
E. surgically treated by pneumonectomy.
3.27 Adenoid cystic carcinoma of the tracheobronchial tree is quite uncommon.
Which of the following statements regarding bronchial adenoid cystic carcinoma is
correct?
A. It has an aggressive course.
B. It has a low rate of recurrence.
C. It has an early onset of distant metastases.
D. The most common histologic type is the cribriform pattern.
E. The cribriform histology has a poor prognosis.
3.28 After a complete resection, the most important factor influencing survival in
patients with carcinoid tumors of lung is
A. cell type (typical versus atypical).
B. location of the tumor (peripheral versus central).
C. postoperative radiation therapy.
D. presence of N
1
disease.
E. tumor size.
3.29 A 50-year-old man with six months history of dyspnoea and hemoptysis was
found to have a solitary, well-demarcated radiopaque mass in the left upper lobe with
associated atelectasis. Flexible bronchoscopy revealed a sessile, smooth, yellow-pink,
lobulated lesion, with intact overlying surface mucosa in the left upper lobe bronchus.
Bronchoscopic biopsy of the mass was reported as composed of groups or sheets of
small, uniform cells arranged in a trabecular pattern, supported by a rich fibrovascular
stroma. Lymphatic or vascular invasion was absent, and no focal necrosis was seen.
Cells were oval or spindle shaped with amphophilic cytoplasm, finely stippled
chromatin, and occasionally nucleoid. Nuclear pleomorphism was not seen, and cells
were predominantly diploid with a low proliferation index (<7% in S-phase). Which of
the following statements about this tumor is true?
A. Cytoproliferative activity in this tumor is generally very high.
B. High-molecular weight cytokeratins are typically found in this tumor.
C. It usually arises in the fifth decade.
D. There is a strong association with smoking.
Shahzad G. Raja
50
E. This tumor accounts for 20% of all lung malignancies.
3.30 Chest radiograph of a 40-year-old man showed a smooth, well-circumscribed
peripheral pulmonary nodule measuring 2.5 cm. Computerized tomography revealed
the presence of “popcorn calcifications” in the nodule. The solitary pulmonary nodule is
most likely a
A. Granular cell tumor
B. Hamartoma
C. Hemangioma
D. Lymphangioma
E. Typical carcinoid tumor
3.31 A 35-year-old man had a solitary pulmonary nodule removed from his left
upper lobe after a parenchymal sparing pulmonary resection. The histology was
reported as benign neoplasm composed of large ovoid or polygonal cells that took up
periodic acid-Schiff stain. The solitary pulmonary nodule is most likely a
A. Granular cell tumor
B. Hamartoma
C. Hemangioma
D. Lymphangioma
E. Typical carcinoid tumor
3.32 Chest radiograph of a 43-year-old man showed a sharply circumscribed
peripheral pulmonary nodule measuring 2.5 cm. There was strong contrast
enhancement of the lesion on computerized tomography. The solitary pulmonary nodule
is most likely a(n)
A. Arteriovenous malformation
B. Hamartoma
C. Hemangioma
D. Lymphangioma
E. Typical carcinoid tumor
3.33 Which of the following characteristics of a solitary pulmonary nodule is
associated with the highest likelihood of malignancy?
A. Age 60-69 years
B. Lobulated mass
C. Not calcified
D. PET SUR >2.5
E. Spiculated mass
3.34 A 62-year-old patient with a 50 pack-year history of smoking was referred to
thoracic surgical outpatient clinic with cough of four weeks duration productive of
whitish sputum. A chest radiograph showed a lower lobe mass and the chest computed
tomographic (CT) scan demonstrated extensive lymphadenopathy, both ipsilateral and
contralateral, and a central mass lesion. Biopsy from bronchoscopy showed molding of
Thoracic Surgery: Questions
51
the cells with the “salt and pepper” chromatin pattern and scant cytoplasm. The
metastatic work-up was negative. The best treatment is
A. high dose radiation therapy.
B. thoracotomy and lobectomy with mediastinal lymph node dissection followed by
postoperative radiation therapy.
C. treatment with cis-platinum and etoposide.
D. treatment with velban, bleomycin and cis-platinum.
E. two cycles of cis-platinum and etoposide with concurrent radiation therapy followed
by thoracotomy.
3.35 A 58-year-old ex-smoker was referred to thoracic surgical outpatient clinic with
cough of four weeks duration productive of whitish sputum. Chest x-ray demonstrated a
< 3 cm coin lesion. The chest computed tomogram was performed which demonstrated
no mediastinal or hilar lymphadenopathy. Needle biopsy of the pulmonary nodule
demonstrated a small cell lung cancer. After an extent of disease evaluation (including
mediastinoscopy) demonstrated no evidence of metastases, the treatment should include
A. chemotherapy only.
B. chemotherapy plus radiation therapy.
C. radiation therapy only.
D. resection plus chemotherapy.
E. resection plus radiation therapy.
3.36 Following cervical mediastinoscopy, a 56-year-old patient underwent a right
upper lobectomy for a 4 cm (T
2
) squamous cell carcinoma of the lung. The final
pathology report notes that two of five intraparenchymal lymph nodes (N
1
) were
positive for metastatic tumor. Which of the following statements regarding adjuvant
therapy is true?
A. Adjuvant Bacillus Calmette-Guerin improves local control.
B. Adjuvant chemotherapy is detrimental to survival.
C. Adjuvant radiation therapy improves local control.
D. Adjuvant radiation therapy improves survival.
E. Predicted three year survival without adjuvant therapy is 70%.
3.37 A 56-year-old patient had successful resection of a stage II non small cell lung
cancer. The single factor most predictive of survival in this patient with a completely
resected stage II non-small cell lung cancer is
A. neoadjuvant radiation therapy.
B. number of metastatic N
1
lymph nodes.
C. postoperative radiation therapy.
D. T status (T
1
versus T
2
).
E. visceral pleural invasion.
3.38 A 58-year-old patient underwent a right lower lobectomy with chest wall
resection for a 2 cm non-small cell lung cancer involving the lateral aspect of the seventh
rib. Pathologic examination of the specimen revealed negative lymph nodes and a
negative margin. The best postoperative management for this patient is
Shahzad G. Raja
52
A. chemotherapy.
B. chemotherapy and radiation therapy.
C. observation.
D. radiation therapy.
E. resection of seventh vertebra.
3.39 A 52-year-old ex-smoker with adenocarcinoma of the right upper lobe has
microscopically positive contralateral (4L) lymph nodes (American Thoracic Society
staging criteria) at mediastinoscopy. The best management plan is
A. induction chemotherapy with cis-platinum and vinblastine followed by thoracotomy
and lobectomy.
B. radiation therapy to 69.6 Gy given in a twice daily fractionation regimen.
C. standard fractionation radiation therapy given concurrently with vinblastine and cis-
platinum.
D. standard fractionation radiation therapy given concurrently with vinblastine and cis-
platinum followed by thoracotomy and pulmonary resection.
E. thoracotomy with lobectomy and complete mediastinal lymph node dissection.
3.40 The computerizd tomographic scanning of the chest and upper abdomen in 58-
year-old ex-smoker with a biopsy proven non-small cell lung cancer (clinical T
1
N
0
)
demonstrated an enlarged left adrenal gland. To evaluate this mass, the next diagnostic
step is
A. abdominal ultrasound.
B. laparoscopy.
C. magnetic resonance imaging.
D. needle biopsy.
E. resection.
3.41 A 52-year-old patient with an otherwise operable non-small cell lung cancer
(T
2
N
0
) was found to have a solitary mass on brain computed tomography. The optimal
treatment for this patient is
A. radiation therapy to brain and lung.
B. radiation therapy to brain and resection of lung disease.
C. radiation therapy to brain and systemic chemotherapy;
D. resection of both the brain metastasis and lung disease.
E. resection of the brain metastasis and radiation therapy to lung.
3.42 Which of the following statements regarding T4 non small cell lung cancer is
correct?
A. Limited local invasion of the
intrapericardial pulmonary artery or left atrium can be
resected
completely with expected 5-year survival rates of ≈ 50%.
B. Superior vena cava resection
is the most accepted extended vascular resection for T
4
disease
with 5-year survival rates
ranging from 40% to 50%
C. Systemic
arterial (aorta) and esophageal invasion of T
4
lung cancer carry
the best long-
term outcome.
Thoracic Surgery: Questions
53
D. T
4
lung cancers invading the vertebral body can be
resected with a 5-year survival rate
of 15%
E. Vascular resection and reconstruction
of the aorta and left atrium have been
safely
described with 5-year survival rates of 40%.
3.43 Which of the following statements regarding chemotherapy for patients with
stage IV non-small cell lung cancer is correct?
A. Cisplatin-based chemotherapy regimens are superior compared to carboplatin-based
regimens.
B. The addition of a third chemotherapeutic agent to existing doublets improves survival.
C. The overall therapeutic efficacy improves with the two chemotherapeutic agents with
no significant cost in toxicity or quality of life compared to single agent.
D. The response rate with two chemotherapeutic agents is similar to that with single
agent.
E. The survival rates with single chemotherapeutic agents are similar to those with two
chemotherapeutic agents.
3.44 Which of the following statements regarding addition of molecular-targeted
agents to established standard double chemotherapeutic agents for non-small cell lung
cancer (NSCLC) is correct?
A. Erlotinib in combination with carboplatin-paclitaxel improves survival in all patients
with advanced NSCLC.
B. Erlotinib in combination with carboplatin-paclitaxel improves survival in patients with
advanced NSCLC with no history of smoking.
C. Gefitinib in combination and carboplatin-paclitaxel improves survival in all patients
with advanced NSCLC.
D. Gefitinib in combination with cisplatin-gemcitabine improves survival in all patients
with advanced NSCLC.
E. Gefitinib in combination with cisplatin-gemcitabine improves survival in patients with
advanced NSCLC with strong history of smoking.
3.45 The stage-specific selection of therapy is the standard for patients with non-
small cell lung cancer (NSCLC). Investigation of the molecular biology of lung cancer
has provided pathways and targets that may be used to improve the efficacy of therapy
and improve the survival for patients with lung cancer. Which of the following
statements regarding molecular staging and the selection of therapy for non-small cell
lung cancer?
A. Epidermal growth factor receptor (EGFr) expression is associated with increased
response to chemotherapy and radiotherapy.
B. Gefitinib is indicated as monotherapy in advanced NSCLC after failure of both
platinum-based and docetaxel chemotherapies.
C. Ligand binding to p53 results in receptor dimerization, autophosphorylation,
activation of cytoplasmic proteins, and eventually DNA synthesis.
D. Studies that evaluate molecular prognostic variables must be limited to the inclusion
of patients with advanced-stage disease.
E. The proto-oncogene c-erbB-1is a tumor suppressor nuclear phosphoprotein.
Shahzad G. Raja
54
3.46 The human p53 protein is a tumor suppressor nuclear phosphoprotein. Which
of the following statements regarding p53 protein is correct?
A. Adenoviral p53 gene therapy combined with radiotherapy in patients with advanced
NSCLC is associated with an improved pathologic control rate.
B. Adenoviral p53 gene therapy is associated with improved survival in patients with
NSCLC.
C. Deletion or mutation of p53 genes is associated with good prognosis in patients with
non-small cell lung carcinoma (NSCLC).
D. Deletion or mutation of p53 genes makes patients more sensitive to chemotherapy or
radiotherapy.
E. p53 activates the growth-arrest pathway to allow DNA repair or the apoptotic pathway
leading to programmed cell death.
3.47 Cyclooxygenase enzymes function to convert arachidonic acids to
prostaglandins. Which of the following statements regarding cyclooxygenase-2 (COX-2)
is correct?
A. Addition of celecoxib to paclitaxel and carboplatin may enhance the response to
preoperative paclitaxel and carboplatin in patients with NSCLC compared with historical
controls.
B. COX-2 expression is associated with decreased tumor invasion, angiogenesis, and
metastasis.
C. Combination of COX-2 inhibitors and platinum compounds reduces the cytotoxicity of
platinum compounds in NSCLC cell lines.
D. Combination of COX-2 inhibitors and platinum compounds results in complete
pathologic responses in patients with stages IB to IIIA non-small cell lung cancer (NSCLC).
E. The cyclooxygenase-2 (COX-2) enzyme produces prostacyclin, which stimulates bcl-2
and thus inhibits apoptosis.
3.48 Which of the following statements regarding molecular biology of non-small
cell lung cancer (NSCLC) is correct?
A. Matrix metalloproteinases (MMP) enhance vascular barriers.
B. Therapy with recombinant humanized anti-vascular endothelial growth factor
antibodies (rhuMAb VEGF) alone is associated with improved response rates and prolonged
time to disease progression in in patients with advanced NSCLC compared with
chemotherapy.
C. The use of marimastat, the first orally available synthetic matrix metalloproteinase
inhibitor (MMPI), is associated with survival benefit and prolongation in time to disease
progression for patients with NSCLC.
D. Vascular endothelial growth factor (VEGF) is strongly induced by hypoxia.
E. VEGF reduces vascular permeability.
3.49 A 50-year-old patient had successful complete resection of superior sulcus non-
small cell lung cancer. Following successful resection, the most important predictor of
survival is
A. histology.
B. intra-operative brachytherapy.
Thoracic Surgery: Questions
55
C. nodal status.
D. pre-operative radiation therapy.
E. postoperative radiation therapy.
3.50 Which of the following statements regarding the anatomy of the superior sulcus
is correct?
A. The apical pleura is the superior most structure in the interscalene compartment.
B. The dorsal scapular artery is present in the interscalene compartment.
C. The subclavian artery is posterior to the middle scalene muscle.
D. The subclavian vein is posterior to the anterior scalene muscle.
E. The trunks of the brachial plexus are anterior to the anterior scalene muscle.
3.51 The chest radiograph below shows left-sided superior sulcus tumor in a 48-
year-old male.
Figure 2.
Which of the following findings on further imaging of the chest will suggest that
resection of this tumor is possible?
A. distant metastatic disease
B. invasion of the brachial plexus roots
C. invasion of more than 50% of a vertebral body
D. invasion of the esophagus
E. tumor adherent to T1 nerve
Shahzad G. Raja
56
3.52 Which of the following statements regarding surgical approaches for resection
of superior sulcus tumor is correct?
A. Anterior transcervical-thoracic approach prevents glenohumeral instability and
functional discomfort.
B. Pneumonectomy is easy to perform through the anterior transcervical-thoracic
approach compared to Shaw-Paulson approach.
C. Posterolateral thoracotomy enables safe excision of tumor involving the subclavian
vein.
D. Shaw-Paulson approach provides excellent access to the middle and anterior
compartments of the thoracic inlet.
E. The combined use of both an anterior and a posterolateral approach is associated with
a higher mortality than the use of either approach alone.
3.53 Which of the following statements regarding detection and treatment of small
intraepithelial and microinvasive preinvasive lesions of lung is correct?
A. Autofluorescence bronchoscopy is more specific than white light bronchoscopy at
detecting carcinoma in situ.
B. Photodynamic therapy produces tumor death by thermal injury.
C. Photodynamic therapy results in a 98% complete response in early lung lesions ≥ 2 cm
D. Recurrence rate following photodynamic therapy for small superficial squamous cell
carcinoma is 30%.
E. The use of high-dose brachytherapy in
three to six sessions results in response rates
superior to
photodynamic therapy.
3.54 Which of the following is the most frequent cause of perioperative mortality
following bronchoplastic procedures?
A. bronchopleural fistula.
B. bronchovascular fistula.
C. empyema.
D. pulmonary embolism.
E. respiratory failure.
3.55 A 55-year-old patient with an FEV
1
of 2.0 liters had a sleeve lobectomy for a
squamous cell carcinoma that involved the origin of the right upper lobe orifice. On the
fifth postoperative day, the patient developed a temperature of 39.0°C and abruptly
coughed up 125 ml of blood. Bronchoscopy reveals an area of partial necrosis at the
anastomosis with fresh clot. The best management is
A. immediate bronchoscopic placement of an endobronchial stent.
B. immediate redo thoracotomy and completion pneumonectomy.
C. immediate redo thoracotomy and wrapping of the anastomosis with intercostal muscle.
D. neodymium-YAG laser ablation of the bleeding area.
E. observation and antibiotics.
Thoracic Surgery: Questions
57
3.56 A 56- year-old patient with FEV
1
= 3 liters underwent a right carinal
pneumonectomy for a squamous carcinoma involving the carinal spur. The anastomosis
was performed with interrupted 4-0 Vicryl
®
and covered with a pleural flap. Which of
the following complications is most likely to occur and to be fatal in this patient?
A. airway stenosis.
B. bronchopleural fistula.
C. bronchovascular fistula.
D. dehiscence at the bronchus.
E. post-pneumonectomy pulmonary edema.
3.57 A patient with a T
1
N
0
lung cancer and diminished pulmonary reserve needs a
pulmonary resection. In making a decision to perform segmentectomy rather than
lobectomy, many factors need to be considered. Which of the following characteristics of
segmentectomy is correct?
A. equivalent local recurrence rate when compared to lobectomy
B. fewer pleural space complications when performed without a stapler compared to
lobectomy
C. reduced air leakage when performed with the classic stripping technique compared to
lobectomy
D. reduced mortality compared to lobectomy patients
E. similar pulmonary function one year after operation compared to lobectomy
3.58 The Medical Research Council LU22 trial investigating whether, in patients
with operable non-small cell lung cancer of any stage, outcomes could be improved by
giving platinum-based chemotherapy before surgery showed that
A. preoperative chemotherapy did not alter the type or completeness of the surgery.
B. preoperative chemotherapy failed to downstage the tumors.
C. preoperative chemotherapy increased postoperative complications.
D. preoperative chemotherapy negatively impacted the quality of life.
E. preoperative chemotherapy produced a benefit in terms of overall survival.
3.59 The postoperative radiotherapy (PORT) meta-analysis evaluates the effect of
postoperative radiotherapy on survival and recurrence in patients with completely
resected non-small cell lung cancer. The meta-analysis
A. showed a significant adverse effect of PORT on survival.
B. showed that PORT improved survival in younger patients.
C. showed that PORT was increasingly detrimental with higher nodal status.
D. showed that PORT was most detrimental for patients with stage III disease.
E. showed that the effects of PORT were more detrimental in those patients with stage II
than with stage I disease.
3.60 A 36-year-old patient is to undergo resection of a solitary metastasis from an
extremity soft tissue sarcoma. When considering a patient for resection of pulmonary
metastases from soft-tissue sarcoma, the factor which most strongly predicts survival is
A. disease-free interval.
B. number of metastases.
Shahzad G. Raja
58
C. resectability.
D. tumor doubling time.
E. unilaterality versus bilaterality.
3.61 The International Registry of Lung Metastases was
established in 1991 to assess
the long-term results of pulmonary
metastasectomy. Analysis of the data collected by
International registry shows that
A. the disease-free interval is not a significant prognostic factor.
B. the number of metastases has no impact on survival.
C. the patients with
germ cell tumors have the worst survival.
D. the survival after a second metastasectomy is remarkably good.
E. the survivals of patients
with epithelial tumors and sarcomas differ significantly.
3.62 The chest radiograph shown below was obtained on postoperative day 2 in a
56-year-old man after right pneumonectomy for multidrug-resistant tuberculosis.
Which of the following statements is correct about the condition shown on the chest
radiograph?
A. It has a reported prevalence of 20%.
B. It is associated with high serum colloidal osmotic pressure.
C. It is associated with a mortality rate of 2.5%-5%.
D. It is diagnosed primarily through a process of exclusion.
E. It occurs more commonly after left pneumonectomy.
Figure 3.