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oncology

Practice targeted AMC-style multiple-choice questions on oncology.

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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old child is brought to the paediatric clinic by their parents due to a 2-month history of increasing abdominal distension, poor appetite, and occasional constipation. On physical examination, a firm, irregular mass is palpable in the upper abdomen, crossing the midline. Vital signs are stable. Initial blood tests, including full blood count and liver function tests, are within normal limits. An abdominal CT scan is performed (image provided). Considering the findings demonstrated in the image, which of the following investigations represents the most appropriate next step in establishing a definitive diagnosis and guiding further management?

A. Surgical resection of the mass
B. Bone marrow aspirate and biopsy
C. Repeat abdominal CT scan in three months
D. Urine catecholamine metabolites (VMA and HVA)
E. Lumbar puncture for cerebrospinal fluid analysis
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 45-year-old male presents with a 3-month history of cough and unintentional weight loss. He is a former smoker. Physical examination is unremarkable. A chest X-ray showed a nodule, and a PET-CT was performed for further characterisation, an axial view is shown. Considering the imaging findings and clinical presentation, what is the MOST appropriate next diagnostic step?

A. Initiate empirical anti-tuberculous therapy
B. Repeat sputum studies for acid-fast bacilli
C. Thoracic surgical referral for wedge resection
D. CT-guided percutaneous biopsy
E. Follow-up PET-CT in 3 months
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 4-year-old boy presents with a 3-week history of decreased appetite, lethargy, and intermittent abdominal pain. His parents note his abdomen seems larger. Vitals are stable. On examination, a firm, irregular mass is palpable in the upper abdomen. Blood work shows mild anaemia. The provided image is an axial CT slice of the abdomen. Considering the clinical presentation and the findings demonstrated in the image, which of the following investigations is the MOST appropriate initial step to support the suspected diagnosis?

A. Bone marrow biopsy
B. Fine needle aspiration of the mass
C. Urinary catecholamine metabolites (e.g., VMA, HVA)
D. Repeat CT scan with contrast
E. Serum alpha-fetoprotein
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents to his GP with a 6-month history of intermittent postprandial fullness and mild dysphagia, particularly with solid foods. He reports occasional regurgitation but denies significant heartburn or chest pain. His vital signs are stable, and physical examination is unremarkable. Recent blood tests show mild iron deficiency anaemia. The provided image is from a CT scan of the chest and upper abdomen performed as part of his investigation. Considering the clinical presentation and the significant anatomical finding demonstrated in the image, what is the most appropriate next step in the management of this patient?

A. Order a barium swallow study
B. Initiate high-dose proton pump inhibitor therapy
C. Referral for surgical assessment and repair
D. Perform an urgent upper endoscopy
E. Advise watchful waiting and lifestyle modifications
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old child is investigated for a 2-month history of increasing abdominal distension and intermittent pain. On examination, a firm, non-tender mass is palpable in the upper abdomen. Initial blood tests reveal mild anaemia. Vital signs are stable. The provided image was obtained as part of the diagnostic evaluation. Considering the clinical presentation and the findings demonstrated, which of the following investigations is most crucial for determining the extent of disease spread, a key factor in guiding subsequent management decisions for this paediatric patient?

A. 123I-MIBG scintigraphy
B. Urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels
C. MYCN gene amplification testing
D. Whole-body PET-CT scan
E. Bone marrow biopsy
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old presents with a 2-month history of increasing abdominal distension and intermittent pain. Physical examination reveals a firm, non-tender mass in the upper abdomen. Blood tests show mild anaemia. Vitals are stable. This CT scan was performed as part of the initial workup. Considering the clinical presentation and the findings demonstrated in the provided image, which of the following investigations is the most critical next step for accurate staging and risk stratification to guide appropriate management in this paediatric patient?

A. Bone marrow aspirate and trephine biopsy
B. Repeat CT scan of the abdomen in 3 months
C. Urgent surgical resection of the mass
D. Genetic testing for WT1 gene mutation
E. Initiation of empirical chemotherapy
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 62-year-old male with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is markedly elevated. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A. Order a CT scan of the abdomen with IV contrast
B. Referral for liver transplant evaluation
C. Initiate systemic chemotherapy
D. Begin palliative care
E. Perform a percutaneous liver biopsy
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 65-year-old patient with a history of smoking presents with a chronic cough and mild weight loss over three months. Physical examination is unremarkable, and vital signs are stable. Routine blood tests, including full blood count and inflammatory markers, are within normal limits. A chest X-ray revealed a solitary pulmonary nodule in the right upper lobe. Subsequent PET-CT imaging was performed as part of the diagnostic workup. Considering the findings demonstrated in the image provided, which of the following is the most appropriate next step in the management of this patient?

A. Refer for surgical resection
B. Bronchoscopy with biopsy or fine needle aspiration
C. Prescribe a course of inhaled corticosteroids
D. Initiate empirical broad-spectrum antibiotics
E. Repeat PET-CT scan in three months
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A 48-year-old woman, who emigrated from Southeast Asia 5 years ago, presents to her general practitioner with a 3-month history of a slowly enlarging lump in her neck. She reports mild fatigue and has lost approximately 3 kg unintentionally over the same period. She denies cough, fever, or night sweats. Her past medical history includes well-controlled type 2 diabetes mellitus managed with metformin. She is a non-smoker and drinks alcohol occasionally. On examination, she has a firm, non-tender, mobile mass measuring approximately 3x4 cm in the left anterior cervical chain. There are no other palpable lymph nodes. Chest auscultation is clear. Abdominal examination is unremarkable. Initial blood tests show a haemoglobin of 118 g/L (normal 120-150), white cell count 7.8 x 10^9/L (normal 4-11), neutrophils 4.5 x 10^9/L, lymphocytes 2.8 x 10^9/L, CRP 15 mg/L (normal <5). Liver and renal function tests are within normal limits. A neck ultrasound confirms a cluster of enlarged, hypoechoic lymph nodes in the left cervical region, the largest measuring 3.5 cm, with some central necrosis noted. A chest X-ray is clear. Given the clinical presentation and investigation findings, what is the most appropriate next diagnostic step?

A. Perform a Mantoux test and Interferon-Gamma Release Assay (IGRA)
B. Order a PET-CT scan to assess for other sites of disease or malignancy
C. Excisional biopsy of the lymph node for histopathology and culture
D. Fine needle aspiration of the lymph node for Ziehl-Neelsen stain, culture, and PCR
E. Initiate empirical treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 68-year-old former smoker with a 30 pack-year history presents to their GP with a 2-month history of persistent cough and increasing fatigue, noting a 3kg unintentional weight loss. Physical examination is unremarkable, and vital signs are stable. Routine blood tests, including full blood count and inflammatory markers, are within normal limits. A chest X-ray reveals a solitary pulmonary nodule in the right upper lobe. Subsequent PET-CT imaging is performed as part of the diagnostic workup. Considering the findings demonstrated in the image provided in the context of this patient's presentation, which of the following is the most appropriate next step in the management of this patient?

A. Repeat PET-CT scan in 3 months
B. Tissue biopsy via bronchoscopy or CT guidance
C. Initiate empirical chemotherapy
D. Initiate empirical anti-tuberculosis therapy
E. Perform pulmonary function tests
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 68-year-old male presents with fatigue, weight loss, and vague abdominal discomfort. His past medical history includes a recent diagnosis of gastric mixed adenoneuroendocrine carcinoma (MANEC). The provided image was obtained as part of his staging workup. Which of the following is the MOST appropriate next step in management?

A. Surgical resection of the affected liver segments
B. Initiation of palliative care and symptom management
C. Observation with serial imaging every 3 months
D. Percutaneous radiofrequency ablation of the largest lesion
E. Referral to medical oncology for systemic chemotherapy
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 68-year-old woman presents to her GP with a 3-month history of a persistent, mildly pruritic skin lesion on her left chest wall. She had a left simple mastectomy for invasive ductal carcinoma 10 years ago, followed by adjuvant therapy. She denies fever, weight loss, or other systemic symptoms. Physical examination reveals the appearance shown. What is the most appropriate initial diagnostic investigation?

A. Prescribe a course of topical antifungal cream
B. Punch biopsy of the lesion
C. Order a PET-CT scan for staging
D. Arrange a follow-up appointment in 3 months to monitor the lesion
E. Perform a shave biopsy of the lesion
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 4-year-old boy presents with left flank pain and a palpable abdominal mass. His mother reports decreased appetite and recent weight loss. A CT scan of the abdomen is performed (image attached). What is the MOST likely diagnosis?

A. Lymphoma
B. Hepatoblastoma
C. Wilms tumor
D. Renal cell carcinoma
E. Neuroblastoma
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 65-year-old male with new onset ascites and elevated ALP has the imaging shown. What is the MOST likely primary malignancy?

A. Colorectal
B. Cholangiocarcinoma
C. Gastric
D. Hepatocellular
E. Pancreatic
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A 45-year-old woman has a mother diagnosed with colorectal cancer at age 55 and a maternal aunt with endometrial cancer at age 60. What is the most appropriate initial step regarding genetic testing for hereditary cancer syndrome?

A. Advise increased surveillance with colonoscopy every 5 years starting now.
B. Order germline testing for MLH1, MSH2, MSH6, and PMS2 genes.
C. Referral to a familial cancer clinic for risk assessment and counselling.
D. Order tumour testing for microsatellite instability (MSI) and immunohistochemistry (IHC).
E. Reassure the patient that this family history is not strongly suggestive of a hereditary syndrome.
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 65-year-old male presents with a 3-month history of unintentional weight loss and early satiety. Gastroscopy and biopsy confirmed a gastric mixed adenoneuroendocrine carcinoma. Staging CT imaging is shown. Considering the clinical presentation and the findings on the provided imaging, what is the most appropriate initial management strategy?

A. Commence somatostatin analogue therapy.
B. Proceed with surgical resection of hepatic lesions.
C. Monitor with serial CT scans and symptomatic management.
D. Initiate systemic chemotherapy.
E. Plan for palliative external beam radiotherapy to the liver.
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 70-year-old man presents with a 3-month history of worsening constipation, occasional bright red rectal bleeding, and unexplained fatigue. His GP notes mild pallor. Full blood count reveals a haemoglobin of 105 g/L and low ferritin. A colonoscopy is performed, and the image provided is a representative view of a finding in the sigmoid colon. Biopsies were taken. Considering the clinical context and the endoscopic appearance, which of the following is the most appropriate next step in the management pathway to determine the extent of disease?

A. Referral for immediate surgical resection
B. Repeat colonoscopy in 6 months to assess response to medical therapy
C. CT scan of chest, abdomen, and pelvis for staging
D. PET scan for metabolic activity assessment
E. Commencement of iron supplementation and review in 4 weeks
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A 25-year-old man presents with a painless testicular lump on the left side, described as a firm intratesticular mass. What is the likely diagnosis?

A. Spermatocele
B. Epididymitis
C. Testicular cancer
D. Hydrocele
E. Hydatid of Morgagni
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

A 62-year-old woman presents for her routine screening mammogram. She reports no breast symptoms, and physical examination is unremarkable. Her medical history includes well-controlled type 2 diabetes and hyperlipidaemia. She has no family history of breast cancer. The provided image is a magnified view from the craniocaudal projection of the right breast. Considering the clinical context and the findings demonstrated, what is the most appropriate immediate next step in the management of this patient?

A. Breast ultrasound of the area
B. Referral to a medical oncologist for systemic therapy planning
C. Repeat screening mammogram in 6 months
D. Stereotactic core needle biopsy of the area
E. Excisional biopsy under wire localisation
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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 62-year-old woman presents with a 4-month history of increasing abdominal distension, bloating, and a sensation of early fullness after eating. She has also noticed a gradual increase in her waist circumference and reports feeling more fatigued than usual. Her medical history includes well-controlled type 2 diabetes mellitus and hypercholesterolaemia, managed with metformin and atorvastatin respectively. She is post-menopausal, having completed menopause 10 years ago. On physical examination, her vital signs are stable: blood pressure 128/78 mmHg, heart rate 68 bpm, respiratory rate 14/min, and temperature 36.6°C. Abdominal examination reveals moderate distension and a firm, irregular mass is palpable extending from the pelvis into the lower abdomen. Bowel sounds are present and normal. A recent transvaginal ultrasound was inconclusive due to the size of the mass, prompting a CT scan of the abdomen and pelvis, an axial image from which is shown. Given the clinical presentation and the findings on the image, what is the most appropriate immediate next step in the management of this patient?

A. Arrange for a fine needle aspiration biopsy of the mass under CT guidance.
B. Prescribe a course of broad-spectrum antibiotics for presumed pelvic inflammatory disease.
C. Schedule a follow-up CT scan in 3 months to monitor for changes in the mass size and appearance.
D. Referral to a gynaecological oncologist and measurement of serum CA-125.
E. Referral to a general surgeon for urgent exploratory laparotomy.
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A 60-year-old woman with a history of breast cancer, treated with surgery and radiation 5 years ago, presents with new-onset back pain. Imaging reveals lytic lesions in the spine. What is the most likely diagnosis?

A. Multiple myeloma
B. Degenerative disc disease
C. Spinal tuberculosis
D. Metastatic breast cancer
E. Osteoporosis
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 4-year-old child is brought to the emergency department with a 3-week history of increasing abdominal distension, intermittent pain, and decreased activity. Parents also report occasional flushing episodes and unexplained fevers. On examination, a large, firm, irregular mass is palpable in the upper abdomen, extending across the midline. Vital signs are stable, and routine blood tests, including full blood count, electrolytes, and liver function tests, are within normal limits. An abdominal CT scan is performed (image provided). Based on the findings demonstrated in the image and the clinical presentation, which of the following investigations is most critical for accurate staging and risk stratification in this likely diagnosis?

A. Serum alpha-fetoprotein and beta-human chorionic gonadotropin levels
B. Upper gastrointestinal series with small bowel follow-through
C. Iodine-123 metaiodobenzylguanidine (MIBG) scan
D. Renal biopsy
E. Colonoscopy
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 58-year-old male with cirrhosis secondary to alcohol abuse presents for routine surveillance. His AFP is 25 ng/mL. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A. MRI of the abdomen with contrast
B. Repeat AFP in 3 months
C. CT of the abdomen with contrast
D. Liver biopsy
E. Initiate sorafenib
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 62-year-old woman presents with fatigue, constipation, and bone pain. Serum calcium is elevated. The provided imaging was obtained. What is the MOST likely underlying cause of her presentation?

A. Parathyroid adenoma
B. Multiple myeloma
C. Thyroid carcinoma
D. Metastatic bone disease
E. Vitamin D deficiency
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 70-year-old male with known cirrhosis secondary to non-alcoholic fatty liver disease is undergoing routine surveillance. His recent surveillance ultrasound identified a new 3 cm lesion in segment VIII. His alpha-fetoprotein level is 45 ng/mL (previously normal). A contrast-enhanced ultrasound is performed, with representative images shown. Based on the clinical context and the findings demonstrated in the images, what is the most appropriate immediate next step in this patient's management?

A. Initiate systemic chemotherapy with sorafenib
B. Repeat the contrast-enhanced ultrasound in 3 months
C. Referral to a multidisciplinary liver tumour board for staging and treatment planning
D. Schedule a follow-up appointment with the GP in 4 weeks
E. Perform an immediate percutaneous biopsy of the lesion
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 65-year-old patient with a history of smoking presents with a chronic cough and mild weight loss over three months. Physical examination is unremarkable, and vital signs are stable. Routine blood tests, including full blood count and inflammatory markers, are within normal limits. A chest X-ray revealed a solitary pulmonary nodule in the right upper lobe. Subsequent PET-CT imaging was performed as part of the diagnostic workup. Considering the findings demonstrated in the image provided in the context of this patient's presentation, which of the following is the most appropriate next step in the management of this patient?

A. Refer for surgical consultation for lobectomy
B. Obtain tissue diagnosis via biopsy
C. Initiate empirical anti-tuberculosis therapy
D. Schedule follow-up CT scan in three months
E. Perform sputum microscopy and culture for acid-fast bacilli
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 65-year-old male with known alcoholic cirrhosis undergoes surveillance. The provided contrast-enhanced ultrasound was obtained. What is the MOST appropriate next step?

A. Repeat ultrasound in 3 months
B. Liver biopsy
C. Initiate sorafenib
D. Ablation therapy
E. Triphasic CT or MRI
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old presents with abdominal distension and bone pain. An abdominal CT is performed (image attached). Which of the following is the MOST appropriate initial investigation to confirm the suspected diagnosis?

A. Urine catecholamine metabolites
B. Liver function tests
C. Bone marrow biopsy
D. Alpha-fetoprotein level
E. Complete blood count
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 62-year-old male presents with a 3-month history of worsening upper abdominal pain, significant fatigue, and a 10 kg unintentional weight loss. His medical history includes long-standing peptic ulcer disease managed with proton pump inhibitors. On examination, he has mild hepatomegaly and trace ascites. Initial blood tests show elevated alkaline phosphatase and gamma-glutamyl transferase, with normal serum bilirubin and transaminases. A contrast-enhanced CT scan of the abdomen and pelvis is performed, and representative images are provided. Considering the clinical presentation and the findings demonstrated on the imaging, which of the following represents the MOST appropriate immediate next step in the management of this patient?

A. Commencement of empirical systemic chemotherapy
B. Urgent upper endoscopy with gastric biopsies
C. Immediate referral to palliative care services
D. Image-guided biopsy of a liver lesion
E. Referral for surgical assessment for liver metastasectomy
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 72-year-old male presents with a 4-month history of increasing fatigue, anorexia, and a 10 kg weight loss. He reports occasional nausea but no vomiting or abdominal pain. His vital signs are stable. Physical examination reveals mild jaundice and palpable hepatomegaly. Blood tests show Hb 105 g/L, elevated AST/ALT, and a mildly raised bilirubin. An upper endoscopy showed a large gastric mass, with histology pending. A CT scan of the abdomen and pelvis was performed. Considering the clinical context and the findings on the provided imaging, what is the most likely implication for this patient's overall management strategy?

A. Referral for liver transplantation assessment.
B. Planning for curative surgical resection of the primary tumour and liver lesions.
C. Urgent initiation of aggressive systemic chemotherapy with curative intent.
D. Focus on symptom control and quality of life measures.
E. Further investigation with MRI liver to characterise the lesions.
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 58-year-old male with cirrhosis presents for routine surveillance. His AFP is 8. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A. Repeat ultrasound in 3 months
B. Start sorafenib
C. Liver biopsy
D. MRI of the abdomen with contrast
E. CT of the abdomen with contrast
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 68-year-old male presents with fatigue, weight loss, and vague abdominal discomfort. His past medical history includes a recent diagnosis of gastric mixed adenoneuroendocrine carcinoma (MANEC). A CT scan of the abdomen is performed. Based on the imaging, what is the MOST appropriate next step in management?

A. Surgical resection of the affected liver segments
B. Initiation of palliative care and symptom management
C. Percutaneous radiofrequency ablation of liver lesions
D. Observation with serial imaging in three months
E. Referral to medical oncology for systemic chemotherapy
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A 35-year-old woman with a family history of BRCA1-associated breast cancer is considering genetic testing. She is asymptomatic and has no personal history of cancer. What is the MOST appropriate initial step in her management?

A. Ordering a BRCA1/2 gene mutation analysis
B. Prescribing prophylactic tamoxifen
C. Suggesting prophylactic bilateral mastectomy
D. Recommending annual mammography starting at age 25
E. Referral to a clinical geneticist or genetic counselor for pre-test counseling and risk assessment
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 62-year-old male with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is elevated. A CT scan of the abdomen with and without contrast is performed, as shown. What is the MOST appropriate next step in management?

A. Start sorafenib therapy
B. Referral for liver transplant evaluation
C. Initiate systemic chemotherapy
D. Perform a percutaneous liver biopsy
E. Order a triple phase MRI of the liver
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 58-year-old male presents with a 3-month history of dyspepsia, early satiety, and unintentional weight loss. Upper endoscopy revealed a large, ulcerated mass in the gastric antrum. Biopsy confirmed adenocarcinoma. Staging investigations were performed, including the provided imaging. His ECOG performance status is 1. Blood tests show mild anaemia and normal liver function tests. Given the clinical presentation and the findings on the provided imaging, which of the following is the most appropriate primary goal of management for this patient?

A. Curative surgical resection of the primary gastric tumour
B. Radiation therapy to the gastric mass
C. Palliation of symptoms and improvement of quality of life
D. Neoadjuvant chemotherapy followed by reassessment for surgery
E. Liver transplantation
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 62-year-old woman presents for a routine follow-up appointment several years after undergoing a simple mastectomy for pT1N0M0 invasive ductal carcinoma of the left breast. She completed adjuvant endocrine therapy and has been well since. During the consultation, she mentions that she has noticed a persistent area of skin change on her left chest wall, near the mastectomy scar, over the past few months. She describes it as occasionally itchy and slightly raised, but denies pain, discharge, or systemic symptoms such as weight loss or fever. Her vital signs are stable, and physical examination reveals no palpable axillary or supraclavicular lymphadenopathy. The appearance of the affected area is shown in the image. Considering the patient's history and the clinical presentation, what is the most appropriate initial diagnostic step?

A. Arrange for a PET-CT scan to assess for metastatic disease
B. Perform fine needle aspiration cytology of the lesion
C. Prescribe a course of topical antifungal cream and review in two weeks
D. Excisional or incisional biopsy of the lesion
E. Reassure the patient that this is likely post-surgical scarring and review in six months
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 72-year-old woman presents with iron deficiency anaemia and a 4-month history of intermittent lower abdominal pain and tenesmus. Colonoscopy was performed, and the image shows a finding in the sigmoid colon. Biopsies are pending but highly suspicious for malignancy. What is the MOST appropriate initial staging investigation?

A. CT scan of chest, abdomen, and pelvis
B. Endoscopic ultrasound
C. PET scan
D. MRI pelvis
E. Bone scan
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 65-year-old male presents with fatigue and occult blood in stool. Colonoscopy findings are shown. What is the MOST appropriate next step in management?

A. Start empiric antibiotics
B. Administer corticosteroids
C. Initiate iron supplementation
D. Repeat colonoscopy in 1 year
E. Surgical resection
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 65-year-old male with recently diagnosed gastric mixed adenoneuroendocrine carcinoma presents with unintentional weight loss. Endoscopy confirmed the diagnosis. Staging imaging is provided. His ECOG performance status is 1. Considering the extent of disease demonstrated, which of the following represents the most appropriate initial therapeutic approach?

A. Gastrectomy with D2 lymphadenectomy
B. Observation with regular imaging surveillance
C. Palliative radiotherapy to the gastric primary
D. Liver resection of dominant lesions
E. Systemic chemotherapy or targeted therapy
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 58-year-old male with a 15-year history of chronic hepatitis B infection and established cirrhosis presents for a routine surveillance appointment. He reports feeling generally well, with no significant weight loss, abdominal pain, or jaundice. He denies alcohol use. On examination, his vital signs are stable. He has mild palmar erythema but no ascites or peripheral oedema. Liver span is normal. Recent blood tests show platelet count 120 x 10^9/L, albumin 35 g/L, INR 1.2, total bilirubin 20 µmol/L, ALT 40 U/L, AST 55 U/L, creatinine 80 µmol/L. Alpha-fetoprotein (AFP) has risen from 50 µg/L six months ago to 450 µg/L today. A triphasic CT scan of the abdomen was performed as part of the surveillance protocol, axial views of which are provided. Considering the patient's clinical history, laboratory trends, and the findings demonstrated on the provided imaging, which of the following represents the MOST appropriate immediate next step in the management of this patient?

A. Proceed directly to percutaneous biopsy of the lesion for histological confirmation.
B. Referral to a multidisciplinary liver tumour board for discussion regarding potential treatment options including liver transplantation.
C. Schedule a follow-up CT scan in three months to assess for interval change.
D. Perform an upper endoscopy to screen for oesophageal varices.
E. Initiate systemic chemotherapy with sorafenib.
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 62-year-old male with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is markedly elevated. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A. Referral for liver transplant evaluation
B. Initiate sorafenib therapy
C. Perform a percutaneous liver biopsy
D. Schedule a follow-up ultrasound in 3 months
E. Order a CT scan of the abdomen with IV contrast
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 45-year-old male presents with a painless lesion on his nose that has been present for several months. He denies any trauma or recent illness. Examination reveals the image shown. What is the MOST appropriate initial management?

A. Observation with serial photography
B. Topical antifungal cream
C. Topical corticosteroid application
D. Biopsy for histopathological examination
E. Cryotherapy
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 62-year-old woman presents for a routine follow-up appointment several years after undergoing a simple mastectomy for pT1N0M0 invasive ductal carcinoma of the left breast. She completed adjuvant endocrine therapy and has been well since, reporting no new systemic symptoms such as unexplained weight loss, fatigue, or bone pain. Her last mammogram of the contralateral breast and clinical examination at her previous visit six months ago were unremarkable. During the current consultation, she mentions that she has noticed a persistent area of skin change on her left chest wall, near the mastectomy scar, over the past few months. She describes it as occasionally itchy and slightly raised, but denies pain, discharge, or significant discomfort. Her vital signs are stable (BP 130/80 mmHg, HR 72 bpm, RR 16/min, Temp 36.8°C). Physical examination reveals no palpable axillary or supraclavicular lymphadenopathy. The appearance of the affected area is shown in the image. Considering the patient's history, the duration and nature of the symptoms, and the clinical presentation, what is the most appropriate initial diagnostic step to investigate this new finding?

A. Prescribe a course of topical antifungal cream and review in two weeks.
B. Perform a punch biopsy of the affected skin area.
C. Arrange for a repeat mammogram of the contralateral breast and ultrasound of the axilla.
D. Order a CT scan of the chest, abdomen, and pelvis to rule out metastatic disease.
E. Reassure the patient that this is likely a benign inflammatory reaction related to the scar and monitor clinically.
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

Mrs. Eleanor Vance, a 62-year-old retired teacher, presents for her routine biennial screening mammogram through the BreastScreen Australia program. She has no personal history of breast disease, and her family history is negative for breast or ovarian cancer in first-degree relatives. She is otherwise healthy, with a history of diet-controlled type 2 diabetes and osteoarthritis managed with paracetamol. She denies any breast pain, lumps, nipple discharge, or skin changes. Her last mammogram two years ago was reported as normal (BIRADS 1). Physical examination of both breasts and axillae is unremarkable. The current screening mammogram is performed. The image provided is a magnified view from the craniocaudal projection of the left breast, specifically highlighting an area that has been flagged for further assessment by the reporting radiologist due to a change from the previous study. Based on the clinical presentation, the patient's history, and the specific finding demonstrated in the provided image from her screening mammogram, what is the most appropriate immediate next step in the management pathway for this patient?

A. Stereotactic vacuum-assisted core biopsy of the suspicious calcifications.
B. Proceed directly to surgical excision of the area under wire localisation.
C. Repeat the mammogram in 3-6 months with spot compression and magnification views.
D. Request a breast MRI with contrast to better delineate the extent of the abnormality.
E. Perform a targeted ultrasound of the area of concern.
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 62-year-old male presents with a 3-month history of rectal bleeding and altered bowel habits. Colonoscopy was performed, and a concerning lesion was identified. What is the MOST appropriate next step in management?

A. Initiate a course of broad-spectrum antibiotics
B. Order a barium enema
C. Biopsy of the lesion
D. Prescribe topical corticosteroids
E. Schedule a repeat colonoscopy in 1 year
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 68-year-old male presents with fatigue, weight loss, and vague abdominal discomfort. His past medical history is significant for a recently diagnosed gastric mixed adenoneuroendocrine carcinoma (MANEC). A CT scan of the abdomen is performed. Based on the imaging, what is the MOST appropriate next step in management?

A. Observation with serial imaging
B. Palliative chemotherapy
C. Liver transplantation
D. Radiofrequency ablation of liver lesions
E. Surgical resection of the primary tumor
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 35-year-old male presents with a two-month history of fatigue, unintentional weight loss, and a persistent dry cough. He denies fever or night sweats. A PET-CT scan of the chest was performed (image shown). What is the MOST appropriate next step in management?

A. Repeat PET-CT in 3 months
B. Initiate anti-tuberculosis therapy
C. Bronchoscopy with biopsy
D. Empiric antibiotic therapy
E. Sputum culture for bacterial pathogens
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 62-year-old woman presents for a routine follow-up appointment several years after undergoing a simple mastectomy for pT1N0M0 invasive ductal carcinoma of the left breast. She completed adjuvant endocrine therapy and has been well since. During the consultation, she mentions that she has noticed a persistent area of skin change on her left chest wall, near the mastectomy scar, over the past few months. She describes it as occasionally itchy and slightly raised, but denies pain, discharge, or systemic symptoms such as weight loss or fever. Her vital signs are stable, and physical examination reveals no palpable axillary or supraclavicular lymphadenopathy. The appearance of the affected area is shown in the image. Considering the patient's history and the clinical presentation, what is the most appropriate initial diagnostic step?

A. Order a whole-body PET-CT scan
B. Reassure the patient and arrange follow-up in 6 months
C. Prescribe a course of topical corticosteroid cream
D. Arrange a mammogram of the contralateral breast
E. Biopsy of the affected skin area
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 72-year-old woman presents with a 6-month history of a non-healing rash on her chest wall at the site of a previous mastectomy performed 10 years prior for invasive ductal carcinoma. She has completed adjuvant chemotherapy and radiation. Examination reveals the findings shown. What is the MOST appropriate next step in management?

A. Skin biopsy of the affected area
B. Topical corticosteroid application
C. Referral for wide local excision
D. Empiric antibiotic therapy
E. Fungal culture of the lesion
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

Mrs. Eleanor Vance, a 62-year-old retired teacher, presents for her routine biennial screening mammogram through the BreastScreen Australia program. She has no personal history of breast disease, and her family history is negative for breast or ovarian cancer in first-degree relatives. She is otherwise healthy, with a history of diet-controlled type 2 diabetes and osteoarthritis managed with paracetamol. She denies any breast pain, lumps, nipple discharge, or skin changes. Her last mammogram two years ago was reported as normal (BIRADS 1). Physical examination of both breasts and axillae is unremarkable. The current screening mammogram is performed. The image provided is a magnified view from the craniocaudal projection of the left breast, specifically highlighting an area that has been flagged for further assessment by the reporting radiologist due to a change from the previous study. Assuming that subsequent investigation of the area highlighted in the image confirms a diagnosis of ductal carcinoma in situ (DCIS) and the patient undergoes breast-conserving surgery, which of the following factors is most important in determining the need for adjuvant radiotherapy?

A. Patient's body mass index (BMI)
B. Margin status of the surgical excision specimen
C. Oestrogen receptor status of the DCIS cells
D. Ki-67 proliferation index of the DCIS cells
E. Presence of metastatic disease on staging scans
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