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Thoracic Surgery: Questions
59
3.63 The chest radiographs shown below were obtained (A) on postoperative day 18
and (B) postoperative day 20 in a ventilated 65-year-old man after right
pneumonectomy for large cell carcinoma.
A
B
Figure 4.
Which of the following statements is correct about the condition shown on the chest
radiographs?
A. It is most commonly seen after lymph node sampling.
B. It is most commonly seen on the left side.
C. It more often occurs within the first two weeks after surgery.
D. The condition is best managed surgically.
E. The most common cause of death associated with this condition is empyema.
Shahzad G. Raja
60
3.64 The chest radiograph and CT image shown below were obtained in a 35-year-
old woman who presented to the Accident & Emergency Department complaining of
exertional dyspnea, inspiratory stridor, and recurrent pulmonary infections. She had
previously undergone right pneumonectomy for multidrug-resistant tuberculosis 11
months ago.
A
B
Figure 5.
What is the most likely diagnosis?
A. Bronchiolitis obliterans organizing pneumonia
B. Esophagobronchial fistula
C. Late-onset postpneumonectomy bronchopleural fistula
D. Late-onset postpneumonectomy empyema
E. Postpneumonectomy syndrome
Thoracic Surgery: Questions
61
3.65 Which of the following statements regarding broncholithiasis is correct?
A. A broncholith is usually formed by aspiration of bone tissue or in situ calcification of
aspirated foreign material.
B. Bronchoscopy is contraindicated for removal of broncholiths.
C. Bronchoscopy often fails to aid in diagnosis.
D. Lithoptysis is the most common mode of presentation of broncholithiasis.
E. The treatment of choice for asymptomatic calcified nodes is surgery.
3.66 Localized fibrous tumors of the pleura (LFTP) are uncommon neoplasms that
have gained increasing recognition over the last 2 decades as a discrete pathologic
entity. Which of the following statements about LFTP is correct?
A. LFTP are associated with prior asbestos exposure.
B. LFTP are predominantly seen in men.
C. LFTP arise from the mesothelial lining of the pleura.
D. LFTP have a peak incidence in the second to third decades.
E. LFTP patients predominantly are symptomatic at presentation.
3.67 A 56-year-old man with hypertrophic pulmonary osteoarthropathy and
hypoglycaemia was noted to have a solid, well-circumscribed mass located at the
periphery of the lung field adjacent to the chest wall on plain chest radiograph. The
most likely diagnosis is
A. bronchial adenoid cystic carcinoma
B. bronchial carcinoid
C. bronchial mucoepidermoid carcinoma
D. hamartoma
E. localized fibrous tumor of the pleura
3.68 Recent advances in immunohistochemical techniques have allowed pathologists
to further differentiate localized fibrous tumors of the pleura (LFTP) from other similar
neoplasms through the development of a relatively unique profile for this tumor. Which
of the following immunohistochemical marker is absent in LFTP?
A. Bcl-2
B. CD34
C. CD99
D. Keratin
E. Vimentin
3.69 Complete surgical resection is the treatment of choice for benign and malignant
localized fibrous tumors of the pleura (LFTP), with 1 to 2 cm margins if possible. Which
of the following statements regarding the rates of tumor recurrence for LFTP is
correct?
A. Patients with benign pedunculated tumors have the highest rate of recurrence.
B. Patients with benign sessile tumors have the highest rate of recurrence.
C. Patients with malignant pedunculated tumors have the highest rate of recurrence.
D. Patients with malignant sessile tumors have the highest rate of recurrence.
E. There is no difference in the rates of recurrence for different histologic types of LFTP.
Shahzad G. Raja
62
3.70 BTS (British Thoracic Society) randomized feasibility study of active symptom
control with or without chemotherapy in malignant pleural mesothelioma: ISRCTN
54469112 showed that
A. a phase III trial comparing ASC with or without chemotherapy is not feasible.
B. chemotherapy with venorelbine was superior compared to MVP regimen.
C. clinically
relevant levels of palliation were achieved with ASC only.
D. randomisation to active symptom control (ASC) with or without chemotherapy
was
unacceptable to patients.
E. the EORTC QL questionnaire was inferior to FACT-L in
terms of completeness of
data and patient preference.
3.71 The randomised trial in malignant mesothelioma (M) of early (E) versus
delayed (D) chemotherapy in symptomatically stable patients (MED trial) showed that
A. delayed use of chemotherapy resulted in better maintenance of quality of life.
B. early use of chemotherapy had no effect on progression of symptoms.
C. early use of chemotherapy offered survival advantage.
D. median time to symptomatic progression was the same in both groups.
E. more health resources were used as a result of delayed use of chemotherapy.
3.72 Which of the following statements regarding myasthenia gravis is correct?
A. In myasthenia gravis patients present with generalized fatigue or pain.
B. In myasthenia gravis ptosis is generally symmetrical.
C. In ocular myasthenia gravis papillary function is abnormal.
D. Isolated oropharyngeal or limb weakness is the most common initial presentation.
E. The onset of myasthenia gravis is influenced by gender and age in a bimodal fashion.
3.73 A 28-year-old-female is diagnosed with myasthenia gravis. Which of the
following statements regarding the etiology of myasthenia gravis is correct?
A. Autoimmune myasthenia gravis results from antibody-mediated, B cell-dependent
immunologic attack on the postsynaptic membrane of the neuromuscular junction.
B. In most cases, antibodies bind to the main immunogenic region of the β-subunit of the
acetylcholine receptor.
C. In myasthenia gravis damage to the postsynaptic membrane results in upregulation of
acetylcholine receptors.
D. Patients with seronegative and ocular myasthenia gravis are more likely to have
thymomas.
E. Thymomas are present in 10% of patients with myasthenia gravis.
3.74 Thymoma is a rare neoplasm usually with an indolent growth pattern. Which
of the following statements regarding thymoma is correct?
A. Thymoma constitutes 90% of all mediastinal tumors.
B. Thymoma is an epithelial tumor.
C. Thymoma is predominantly seen in early teens.
D. Thymoma is most commonly associated with hypogammaglobulinemia.
E. Thymoma primarily affects females.
Thoracic Surgery: Questions
63
3.75 Which of the following is the radiologic examination of choice for evaluation of
all mediastinal masses in the anterior compartment?
A. Chest CT scan with intravenous contrast
B. Chest x-ray
C. Echocardiography
D. Fluoroscopy
E. Positron Emission Tomography
3.76 Thymomas are classified according to their neoplastic (epithelial) and
nonneoplastic (lymphocyte) components. It is not uncommon to have more than one
histologic subtype within a single tumor. Which of the following statements regarding
histology of thymomas is correct?
A. The spindled epithelial cells of type A thymoma express the B-cell marker CD20.
B. Type A thymoma has abundant lymphocytes.
C. The type A thymomas have ovoid or polygonal epithelial cells and immature, cortical-
type (double CD4+ 8+, CD1a+, TdT+) thymocytes.
D. Type A thymomas are significantly more likely to be higher stage than type B
thymomas.
E. The type B thymoma has neoplastic epithelial cells that assume an elongated or
spindle cell appearance.
3.77 Type B thymomas are further subdivided into three subtypes B1, B2, and B3.
Which of the following statements regarding these subtypes of type B thymomas is
correct?
A. A hallmark of type B2 thymoma is the presence of focal medullary differentiation.
B. Cortical-type (double CD4+ 8+, CD1a+, TdT+) thymocytes are most abundant in type
B3 thymoma.
C. Type B1 has the highest ratio of epithelial cells to thymocytes.
D. Type B2 has the highest ratio of epithelial cells to thymocytes.
E. Type B3 has the highest ratio of epithelial cells to thymocytes.
3.78 A 52-year-old man was diagnosed with a stage III B thymoma. Stage III B
thymoma
A. has microscopic transcapsular invasion.
B. has macroscopic invasion into surrounding fatty tissue or grossly adherent to but not
through mediastinal pleura or pericardium.
C. has macroscopic invasion into neighboring organs (i.e., pericardium, great vessels,
lung) without invasion of great vessels.
D. has macroscopic invasion into neighboring organs (i.e., pericardium, great vessels,
lung) with invasion of great vessels.
E. is macroscopically and microscopically completely encapsulated.
3.79 Which of the following statements about the prognosis of thymic tumors is
correct?
A. Myasthenia gravis is a negative prognostic factor for long-term survival.
B. There is no difference in survival between between Masaoka Stage I, II, and III.
Shahzad G. Raja
64
C. There is significant difference in survival between Masaoka Stage III and IV.
D. The size of thymoma does not influence survival.
E. The WHO histology does not influence survival.
3.80 Which of the following statements regarding thymic tumors is correct?
A. Chemotherapy results in complete cure of stage IV thymic tumors.
B. Response rates to chemotherapy in the metastatic setting range from 30% to 60%.
C. The majority of patients with thymic tumors present with late stage disease.
D. Thymic tumors are predominantly non-surgical diseases.
E. Thymic tumors are resistant to chemotherapy.
3.81 A 59-year-old man was diagnosed with malignant thymoma. Which of the
following statements regarding malignant thymomas is correct?
A. Intrathoracic recurrence can develop after complete surgical resection in up to 40% of
those with invasive disease.
B. Invasive thymomas are radioresistant.
C. Malignant thymomas are usually rapidly-growing tumors with an aggressive natural
history.
D. Patients with Masaoka stage II disease with fibrous adhesion to the mediastinal pleura
have similar recurrence rates to those without fibrous adhesions to the mediastinal pleura.
E. Postoperative radiation therapy decreases the incidence of subsequent pleural
dissemination in completely resected invasive thymoma.
3.82 Which of the following statements regarding the treatment of thymic tumors is
correct?
A. For locally advanced, large, invasive thymomas that are unresectable or marginally
resectable, preoperative adjuvant radiation therapy fails to render it resectable.
B. For stage III/IV disease, the evidence supporting the use of postoperative radiation
therapy is lacking.
C. Induction chemotherapy may be effective at down-staging thymoma.
D. Neoadjuvant chemotherapy followed by surgery and adjuvant radiotherapy has no
impact on the survival of patients with locally advanced thymoma.
E. Postoperative radiotherapy for thymic carcinoma offers a survival benefit.
3.83 A 36-year-old man with chest discomfort had a chest radiograph that showed a
well-defined lobulated
mass in the anterosuperior mediastinum. Full blood count
revealed pure red cell aplasia. Further evaluation with contrast-enhanced
thoracic CT
scanning (Figure) revealed a mass with a heterogenous high-attenuated solid upper
portion (arrow) with a small calcification in the left anterior aspect of the main
pulmonary artery. What is the most likely diagnosis?
A. Benign mediastinal teratoma
B. Invasive thymoma
C. Mediastinal goiter
D. Mediastinal parathyroid adenoma
E. Mediastinal seminoma
Thoracic Surgery: Questions
65
Figure 6.
3.84 A 45-year-old male complaining of cough and shortness of breath had a
contrast-enhanced CT scan showing a necrotic mass with an irregularly shaped
enhancing wall in the right anterior mediastinum (Figure). CT-guided biopsy of the
mass showed a predominance of lymphoepitheliomatous cell types with high-grade
atypia, necrosis, and > 10 mitoses per high-power
field. Clinical examination was
unremarkable. What is the most likely diagnosis?
A. Benign mediastinal teratoma
B. Mediastinal goiter
C. Mediastinal parathyroid adenoma
D. Mediastinal seminoma
E. Thymic carcinoma
Figure 7.
Shahzad G. Raja
66
3.85 A 16-year-old boy with new onset cough had a chest x-ray that showed
mediastinal widening. CT scan (Figure) showed a heterogeneous left anterior
mediastinal mass containing soft-tissue, fluid, and fat. Clinical examination was
unremarkable. What is the most likely diagnosis?
A. Benign mediastinal teratoma
B. Mediastinal goiter
C. Mediastinal parathyroid adenoma
D. Mediastinal seminoma
E. Thymic carcinoma
Figure 8.
3.86 Which of the following statements regarding mediastinal seminoma is correct?
A. Surgery is the treatment of choice for locally advanced seminomas.
B. Primary mediastinal seminomas comprise 10
to 15% of malignant mediastinal germ
cell tumors.
C. Primary mediastinal seminomas occur most frequently
in men ages 20 to 40 years.
D. Radiographically, seminomas appear as a homogeneous cystic mass.
E. Seminomas are uniquely resistant to radiation therapy.
3.87 Which of the following statements regarding mediastinal nonseminomatous
germ cell tumors (GCTs) is correct?
A. An elevated α-fetal protein (AFP level) is suggestive of an endodermal sinus tumor.
B. In contrast to pure
seminomas, nonseminomatous GCTs carry a better prognosis.
C. Surgery is the
current standard of care for patients with nonseminomatous malignant
GCTs.
D. These tumors are often
asymptomatic.
E. They are predominantly benign.
Thoracic Surgery: Questions
67
3.88 Which of the following statements regarding primary mediastinal Hodgkin
lymphoma is correct?
A. For patients with
Hodgkin disease who relapse allogeneic bone marrow transplant
(BMT) is superior to autologous BMT.
B. Lymphocyte-rich subtype represents two thirds of cases of mediastinal Hodgkin
disease.
C. MOPP chemotherapy regimen is superior to ABVD regimen in preventing relapse.
D. Hodgkin lymphoma represents approximately 50 to 70% of mediastinal lymphomas.
E. Patients with favorable stage I & II Hodgkin disease have cure rates of < 50% with
standard treatment.
3.89 A 49-year-old man with fever, cough and chest pain had a chest x-ray that
revealed a rounded mass (arrow) that displaced the right primary bronchus superiorly
(Figure A). A sagittal T1-weighted magnetic resonance image (Figure B) of the same
mass is also shown. Thoracoscopic needle aspiration of the mass showed ciliated,
pseudostratified, columnar epithelium. What is the most likely diagnosis?
A. Bronchogenic cyst
B. Enterogenous cyst
C. Lymphangioma
D. Neuroenteric cyst
E. Pericardial cyst
Figure 9.
Shahzad G. Raja
68
3.90 Which of the following statements regarding the enterogenous cysts is correct?
A. Enterogenous cysts are associated with multiple vertebral
anomalies.
B. Enterogenous cysts are lined with ciliated, pseudostratified, columnar epithelium.
C. Enterogenous cysts are identified in the fourth to fifth decade of life.
D. Enterogenous cysts arise from the ventral foregut.
E. Enterogenous cysts can be difficult to distinguish from
bronchogenic cysts,
radiographically.
3.91 Which of the following statements regarding the pericardial cysts is correct?
A. Pericardial cysts are predominantly acquired.
B. Pericardial cysts are identified in the first decade of life.
C. Pericardial cysts are most commonly located at the left cardiophrenic angle.
D. Pericardial cysts appear as multiloculated masses on CT scan.
E. Pericardial cysts form as a result of a persistent parietal recess
during embryogenesis.
3.92 Which of the following statements regarding the lymphangiomas is correct?
A. Lymphangiomas are commonly found in teens.
B. Lymphangiomas are found in the cervical region 75% of the time.
C. Lymphangiomas in 90% of the cases are associated with chylothorax and
hemangiomas.
D. Lymphangiomatosis is commonly seen in young men.
E. Lymphangiomas typically are widespread.
3.93 Which of the following statements regarding the neurogenic tumors is correct?
A. Nerve sheath tumors comprise 40 to 65% % of neurogenic
mediastinal masses.
B. Neurofibromas are firm, encapsulated
masses consisting of Schwann cells.
C. Neurogenic tumors comprise 95% of all mediastinal masses.
D. Ninety percent of neurogenic tumors are asymptomatic.
E. Seventy
percent to 80% of neurogenic tumors are malignant.
3.94 Which of the following statements regarding the autonomic ganglionic tumors
is correct?
A. Ganglioneuromas are the least benign of the autonomic ganglionic
tumors.
B. Ganglioneuroblastomas are the most common type of neurogenic
tumor.
C. Ninety percent of neuroblastomas arise in the adrenal glands.
D. On CT scan, 80% of neuroblastomas have calcification.
E. Treatment of neuroblastomas is predominantly radiotherapy.
3.95 Which of the following statements is true regarding chronic fibrosing
mediastinal inflammation?
A. Airway obstruction is alleviated by excising granulomatous lymph nodes around
airways.
B. Antifungal therapy is effective treatment.
C. It is caused by tuberculous infection in the majority of cases.
D. Unresolved superior vena caval syndrome is the major cause of morbidity.
E. Venous bypass is rarely indicated.