STUDENT NAME_____________________________ STUDENT ID NUMBER_______________ STUDENT NAME_____________________________ STUDENT ID NUMBER_______________

Ollscoil na hÉireann Gaillimh CANCER STUDIES AND IMAGING

National University of Ireland, Galway 1. Which one of the following is an indication for performing MRI scanning of the breast?
Specialist Clinical Practice – MD505
A. Follow up of suspected axillary nodal metastases
Semester II Examination – April 26, 2013
B. Further evaluation of microcalcifications seen on an earlier mammogram
Paper I – Single Best Answer Multiple Choice Questions
C. Further evaluation of a small well circumscribed soft tissue mass on a breast
ultrasound scan
Examiners
MRI Indications: D. Screening of elderly patients (over 70 years) on hormone replacement therapy
Dr. John Carey, Mr. Aidan Devitt, Dr. Sean Dinneen, Dr Yvonne Finn, Dr. Gerard Flaherty, Prof. - Screening high risk pt
Matt Griffin, Dr. Fiona Harney, Prof. Michael Kerin, Dr. Timothy Counihan, Mr. Jack Kelly, - Mammographically occult -
E. Screening of pre-menopausal patients with the BRCA-1 or -2 mutation
Dr. Trevor Markham, Prof. Timothy O’Brien, Prof. Michael O’Dwyer, Prof. Peter McCarthy, Widespread DCIS
- Lobular Carcinoma
Prof. Frank Sullivan, Dr. Dympna Waldron, Mr. Killian Walsh - Neoadjuvant therapy
- Suspected recurrence in
reconstructed breast
- Patients with breast implants
2. The sensitivity and specificity of MR imaging is superior to CT scanning in the staging of
which the following malignancies?
Duration: 2 hours

MRI has better spatial

A. Assessment of prostate carcinoma involvement of the seminal vesicles resolution than CT
Please select the single most correct response from the five options provided in B. Assessment of prostate carcinoma with nodal metastases in the pelvis
each case and clearly mark your response in UPPER CASE LETTERS in the box
provided to the left of each question. C. Locally advanced bronchial carcinoma
D. Renal cell carcinoma confined to the kidney
Please ensure that your name and ID number are recorded on each page of this
question/answer book. E. Transitional cell carcinoma of the renal pelvis

Please refer to the table of normal laboratory reference range values on the last
page of this question paper in interpreting the laboratory values provided in each
question. 3. A 52 year old man with a history of hormone-refractory prostate cancer, and leg

Drug names are listed in generic form. weakness on clinical exam, is found to have spinal cord compression at T12 on
MRI. The most appropriate next step in management is:
___________________________________________

A. Confirmatory biopsy Treatment of spinal cord compression: Give

urgent Dexamethosone in malignancy while
B. Loading dose of IV steroids considering more specific tx

C. Orthopaedic opinion
D. Physiotherapy
3-5% of cancer patients have spinal mets. 15% of those with advanced Ca develop
E. Radiotherapy metastatic spinal cord compression. Most commonly associated with lung, prostate,
breast, myeloma and melanoma. Urgent tx required to preserve neuro function and
relieve pain.
Signs& Sx: back pain in 95%. Nocturnal pain and pain with straining. Worry if there is
cervical/thoracic pain. Also limb weakness, difficulty walking, sensory loss, bowel/
1 2
bladder dysfunction.
Management: Admit for best rest & arrange urgent MRI of whole spine. Give
Dexamethasone 16mg/24h PO with prophylactic gastric protection & blood glucose
monitoring. VTE prophylaxis as reduced mobility TEDS etc. Refer uregently for MDT
discussion. RadioT is the commonest tx and should be given within 24 hrs of MRI dx.
Decompressive surgery ± radiotherapy may be appropriate depending on prognosis.
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4. A 65 year-old woman, known to have bone metastases from breast cancer, presents to 7. A 65 year old man presents with painless lymphadenopathy. Physical examination
A & E with back pain. Examination reveals lower limb weakness with upper motor reveals generalized lymphadenopathy, with non-tender, rubbery lymph nodes as
neurone signs and a sensory level just below the nipple line. The most appropriate next well as hepatosplenomegaly. Which of the following is not in keeping with a
investigation is: diagnosis of low grade lymphoma?

A. CT Spine A. It is considered incurable with standard therapy

B. MRI Thoracic spine B. There is low FDG uptake on PET scan
C. MRI Whole spine C. Patients are often asymptomatic at initial presentation
D. Neurological consult D. It requires urgent treatment with combination chemotherapy and rituximab
E. Plain film Thoracic spine E. It usually presents with advanced phase disease

5. A 60 year-old female with advanced ovarian cancer is admitted with abdominal pain,
nausea and intermittent vomiting. A CT abdomen confirms bowel obstruction 8. A 50-year-old man presents with painful ribs. His Haemoglobin is 9g/dl and serum
secondary to metastatic disease. The most appropriate anti-emetic is: creatinine 180μmol/L. A chest x ray shows pathological rib fractures. Serum
protein electrophoresis shows a monoclonal IgA lambda protein of 30g/L and a
A. Cyclizine
bone marrow biopsy contains 50% plasma cells. Which of the following
B. Domperidone
investigations is not indicated?
C. Hyoscine hydrobromide
Metclopromide: exacts anti-emetic effects by
D. Metoclopramide antagonizing Dopamine D2 receptors, but also has
prokinetic effects (due to partial 5-HT4 agonist
E. Prochlorperazine activity) A. Beta 2 microglobulin Prognostic Myeloma diagnosis: Have a high index of suspicion—
in bone pain or back pain that is not improving. Check
B. Bone Scan blood film and electrophoresis.
Diagnostic criteria
C. MRI 1 Monoclonal protein band in serum or urine
6. A 74 year-old gentleman with metastatic prostate carcinoma is admitted for pain electrophoresis
D. Serum Albumin 2 increased plasma cells on marrow biopsy
control. His pain is poorly controlled on his current dose of morphine sulphate and 3 evidence of end organ damage from myeloma:
hypercalcaemia, renal insufficiency, anaemia
E. Skeletal Survey
he is experiencing somnolence and myoclonic jerking. Blood investigations reveal a 4 Bone lesions: a skeletal survey after diagnosis
detects bone disease: xrays of chesk, all of spine,
urea of 18 mmol/L and a creatinine of 267μmol/L. The most appropriate opioid in skull pelvis ± Tc99m MIBI & PET.
Bone scan picks up
managing his pain is: osteoblastic activity-
myeloma more osteolytic

A. Codeine
Hepatic metabolism.
B. Fentanyl 100x stronger than morphine.
C. Oxycodone
D. Pethidine
E. Tramadol

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DERMATOLOGY/PLASTIC SURGERY D. Scabies

E. Urticaria
9. A 53 year old man presents with a six month history of a rash on the palms of his
hands. On closer examination the rash consists of a background of well defined
erythema with scaling and pustules. The most likely diagnosis is: 12. A 17 year old lady with a background history of psoriasis presents to the
outpatients department with a 6 week history of a rash on her ears and abdomen.
A. Allergic hand dermatitis
Examination of the ear lobes and peri-umbilical area revealed erythematous scaly
B. Irritant hand dermatitis
plaques with secondary crusting and fissures. The most likely diagnosis is:
C. Palmar psoriasis
D. Lichen planus
E. Tinea infection A. Allergic contact dermatitis
B. Lichen planus
C. Mycosis fungoides
10. A 20 year old woman presents with a 3 week history of an itchy generalised rash.
D. Psoriasis
The rash began 3 days after an upper respiratory tract infection. The rash is not
E. Tinea corporis
constant and consists of pink dermal plaques of varying shapes and sizes. The most
likely diagnosis is:
Guttate 13. A 49 year old man is burned in a house fire and is found to be unconscious. He is
transferred to the emergency room and is assessed. After full ABC resuscitation, he
A. Cutaneous lupus
has a 45% burn, including a deep circumferential burn around the left upper limb
B. Eczema
and chest. He is intubated, catheterised and IV access is achieved. He is beginning
C. Psoriasis
full fluid resuscitation and blood is cross-matched. Which of the following could be
D. Scabies
required as an emergency procedure?
E. Urticaria

A. Burr Hole to the skull

11. An 85 year old man presents to the emergency department with an itchy rash for
B. Chest drain to left chest
the last month. An examination of his skin revealed a symmetrical eruption
C. Escharotomy to left upper limb and chest
consisting of widespread erosions and multiple large tense blisters on an
D. Release of left carpal tunnel
inflammatory base. The most likely diagnosis is:
E. Skin graft to chest and left upper limb
A. Bullous pemphigoid
B. Dermatitis herpetiformis
C. Pemphigus vulgaris 14. A 24 year old man, injured in a motorcycle accident, was admitted and had an
intramedullary nail inserted into the right tibia. The following day the plastic

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surgery team was called to assess the soft tissue injury and noted abrasions to the A. The abductor pollicis brevis
leg and thigh. There was no laceration and the fracture was a closed injury. The B. The extensor communis
patient is now complaining of severe pain in the leg, which is increasing in severity. C. The extensor hallucis longus.
Which of the following is most likely the cause of the severe pain? D. The flexor digitorum profundus.
E. The flexor pollicis longus
A. The abrasions are becoming infected
Pain out of proportion to the clinical signs.
B. The patient may have developed compartment syndrome Pain on passive movement of the leg
C. The patient might have a skull injury and be confused
D. The patient’s fracture is not properly united
NEPHROLOGY/UROLOGY
E. The patient’s morphine dose is not adequate
17. A 68-year old woman with end-stage renal failure due to hypertensive
nephrosclerosis has been receiving chronic haemodialysis three times a week for
3.5 hours per session through a left forearm arterio-venous fistula for the past 6
15. A 64 year old musician is referred with pain and paraesthesiae in the right hand for
years. Over the last 3 months her dialysis efficiency, as reflected in urea reduction
the last 6 months. He describes numbness at night and clumsiness. There is no
ratio, has become progressively worse and the dialysis machine has been alarming
history of trauma and he is otherwise well. You suspect Carpal Tunnel syndrome.
frequently because of high pressure in the venous return system. Which of the
Which of the following would support your diagnosis?
following would best explain this presentation? Kt/V

A. A clawing deformity of the little and ring fingers A. Acute thrombosis of the arterio-venous fistula.
B. A positive Froment’s sign B. Congestive heart failure.
C. A positive Tinel’s sign at the elbow C. Malfunction of the dialysis machine.
D. Inability to abduct the little finger D. Stenosis of the arterio-venous fistula.
E. Wasting of the thenar eminence E. Sub-acute bacteraemia.

18. A 25 year old man with a history of social difficulties and heavy drinking is brought
16. A 26 year old tag rugby player attends the Emergency Department after catching his unconscious to the Emergency Department. Urgent laboratory test results include:
finger in another player’s jersey. He complains of pain in the ring finger and Sodium 130 mmol/L; Potassium 3.6 mmol/L; Chloride 98 mmol/L; Bicarbonate 6
swelling. An x-ray is normal and there is no laceration to be seen. He is not able to mmol/L; Urea 16.5 mmol/L; Glucose 5.4 mmol/L; Creatinine 243 µmol/L; pH 6.98;
pull the ring finger fully into the palm and it sticks out, making a pointing sign. All pO2 14.4 kPa; pCO2 2.1 kPa; serum osmolality 314 mosmol/L. Based on these results,
the other fingers bend into the palm. Which of the following tendons might be the anion gap is calculated as 30 and the osmolar gap as 32. Lactic acid and ketone
Pre renal? U:Cr.
ruptured?

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levels in the blood are within normal ranges. Which of the following best explains the A. His brother will not be able to donate to him because of blood group
laboratory abnormalities in this patient: incompatibility.
B. His history of colon polyps makes him unsuitable for transplantation.
A. Acute renal failure due to volume depletion. C. His long-term survival will be better if he remains on dialysis for at least a year
B. Ethylene glycol ingestion Lactate HIGH??? before considering a transplant.
C. Non-ketotic hyperosmolar coma. D. His native kidneys should be removed to reduce the likelihood of recurrent IgA
D. Salicylate overdose. Lactic acid high nephropathy after transplantation.
E. Severe ethanol intoxication E. If he receives a living donor transplant it is more likely to function for 20 years
or more than a deceased donor (“waiting list”) transplant.

19. A 28 year old man has had type 1 diabetes mellitus for 12 years and has the
following results recorded during a routine outpatient visit: Serum creatinine 72
μmol/L, eGFR 84 ml/min, serum sodium 142 mmol/L, serum potassium 3.8 mmol/L, 21. An elderly man is referred to the urology clinic with lower urinary tract symptoms. He
urine albumin creatinine ratio 10 mg/mmol (normal 0 to 3.5 mg/mmol), HbA1c 46 is requested to complete the International Prostate Symptom Score (IPSS)
mmol/mol (normal 20 – 42 mmol/mol). His BMI is 24 and his last three clinic BP questionnaire. Which of the following is not assessed on the IPSS questionnaire?
measurements have been 152/92, 148/88 and 154/90. Which of the following is most
A. Frequency
appropriate to introduce in response to these results?
B. Incomplete emptying
C. Incontinence
A. Diet and lifestyle changes
D. Quality of life
B. Frusemide 20mg daily
E. Straining
C. Hydrochlorothiazide 25mg daily
D. Intensive insulin therapy
E. Ramipril 5 mg daily.
22. A 64 year old male is diagnosed with prostate cancer with lumbar vertebral
metastases. Communication between the prostate venous plexus and lumbar
venous plexus is via which of the following? Batson’s plexus

20. A 54 year old man who has just started peritoneal dialysis for end-stage renal failure A. External iliac veins

due to IgA nephropathy is being evaluated for kidney transplantation. His past B. Gonadal veins

medical history also includes treated hypertension, gout and benign colon polyps. His C. Inferior rectal veins

blood group is AB. He has a healthy brother whose blood group is A. Which of the D. Internal iliac veins

following statements is correct? E. Superior rectal veins

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23. A 64 year old female complaining of urinary frequency is diagnosed with overactive C. Hypoglycaemic episode
bladder. Which of the following medications is first line in managing this D. Reflex anoxic seizure
condition? E. Vasovagal syncope

A. 5 Alpha-reductase inhibitor
26. A 70 year old widower complains of new onset daily persistent headache of three
B. Alpha blocker
months duration. He also complains of fatigue and diffuse myalgias. The most
C. Anti-cholinergic
important initial investigation is:
D. BCG
E. Intra-vesical botulinum
A. Carotid Ultrasound
B. Creatine kinase (CK) level
C. CT scan of the brain
24. A 56 year old smoker undergoes a transurethral resection of bladder tumour (TURBT).
D. ESR
Histology confirms a transitional cell carcinoma (TCC) bladder. Which additional
E. Urgent referral to the Psychiatric Services
pathological finding would indicate stage T2 or greater?

A. Detrusor muscle invasion 27. A 65 year old woman is referred for assessment of painless diplopia. On
B. Gleason grade examination the only abnormalities are incomplete abduction of the left eye and
C. Lymphovascular invasion ipsilateral partial ptosis. The most likely diagnosis is:
D. Mitotic number
E. Perineural invasion A. Horner Syndrome
B. Internuclear ophthalmoplegia
C. Myasthenia gravis
D. Sixth cranial nerve palsy
E. Third cranial nerve palsy
NEUROLOGY/OPHTHALMOLOGY

25. A 16 year old school girl has a witnessed collapse while en route from lunch to her
classroom. She is initially described as pale, limp and clammy. As she is helped into 28. In a patient who exhibits marked worsening of ataxia with eye closure (Romberg
a chair, she is noted to have brief tonic-clonic movements. After being helped to Anoxic
sign), the most likely anatomical site of the lesion is:
the chair she regains full consciousness. She is fully alert and oriented within a
minute or two thereafter. The most likely diagnosis is: A. Cerebellum
B. Cortico-spinal tract
A. Addisonian crisis
C. Posterior columns
B. Convulsive seizure
D. Spinothalamic tract

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E. Vestibular apparatus 32. A 42 year old female presents with a painful red eye with reduced vision. Which of
the following is the most correct statement?
29. Which of the following statements is true about macular degeneration?
A. An abnormal CXR may be significant
A. Lutein supplements reverse dry macular degeneration changes B. Central serous retinopathy is among the differential diagnoses
B. Intraretinal and subretinal fluid are seen on OCT scan in wet degeneration C. H.I.V retinopathy is likely
C. Involvement of both eyes is rare D. Ischaemic maculopathy is likely
D. PDT laser may have a role in dry degeneration E. Swelling of the extra-ocular muscle tendon may be seen
E. Retinal fluorescein angiogram shows fluid leakage in dry degeneration

30. A seventy five year old man complains of sudden painless loss of vision in one eye.
RHEUMATOLOGY/ORTHOPAEDICS
Which of the following statements is the most likely explanation for this
presentation?

33. All of the following drugs have been shown to lower uric acid except:
A. Dry macular degeneration
B. Optic neuritis A. Allopurinol
C. Posterior communicating artery aneurysm B. Angiotensin Receptor Blockers
????
D. Retinal detachment C. Febuxostat These all lower Uric acid
E. Rubeotic glaucoma D. Leflunomide
E. Non-steroidal anti-inflammatory drugs

31. A 55 year old type 2 diabetic man with poorly controlled hypertension and HbA1C
of 85mmol/mol (normal range 20-42 mmol/mol) complains of gradual reduction in 34. Results from the Global Burden of Disease 2010 study published in the Lancet in 2012
vision in the left eye. Examination of the left retina shows fluid and hard exudates. show the single leading cause of disability among adults of almost 200 countries
Which of the following statements is most accurate? was:

A. Knee pain
A. Anti- VEGF intravitreal treatment may improve vision
B. Low back pain
B. Giant cell arteritis is the likely diagnosis
C. Neck pain
C. Proliferative diabetic retinopathy is a likely diagnosis
D. Osteoarthritis
D. PRP laser is mandatory
E. Osteoporosis
E. Retinal detachment is likely

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35. An elderly female was recently diagnosed with “severe osteopaenia” following a
hip fracture, and DXA T-score of -2.2 at the spine. You note she is not on
treatment. Which of the following statements about diagnosis and/or
management is most appropriate?
A. She has osteoporosis, is at increased risk of fracture and should start treatment as
soon as possible
B. She has ‘osteopaenia’ rather than ‘severe osteopaenia’ and should talk to her doctor
about this
C. She is lucky that she only has osteopaenia and not osteoporosis
D. She has a low risk of fracture currently, but is at risk of developing osteoporosis in
later life
E. She has osteoporosis and osteopaenia and unfortunately it is too late to do anything
about it
36. Your next patient in the rheumatology clinic is a 34 year old female who tells you she
has a diagnosis of “lupus”. She tells you that her GP recently told her she might not
have lupus because her anti-nuclear antibody (the ANA test) was negative. You
explain that because this is a very sensitive test the most appropriate
interpretation is:
A. It is most likely she has lupus and the result of this test doesn’t matter
B. It is most likely she doesn’t have lupus and the results are very helpful
C. It is most likely she has lupus and this result is very concerning
D. Results like this are not very helpful
E. This test should be repeated
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37. Regarding patients undergoing total hip replacement which of the following
statements is true?
A. A pyrexia of 38.7 degrees Celsius in the first 24 hours post operatively is likely to
be due to infection of the prosthetic joint
B. Joint infection can occur early in the post operative period or several years later
by delayed haematogenous route
C. Patients are confined to bed for 48 hours post operatively in an abduction pillow
to reduce the risk of dislocation
D. Prophylactic antibiotics are given at induction and continued for 5 days
E. The incidence of fatal pulmonary embolism post operatively is 2%
38. A 20 year old hockey player sustains a twisting injury to the knee during a match.
He is unable to play on, the knee swells within 1 hour and he presents 3 days later
to his GP complaining of a sense of giving way and pain on the medial side of his
knee. Which one of the following statements is most correct?
A. Aspiration of his joint should be carried out by the GP to facilitate clinical evaluation of
instability of the knee
B. A combined posterior cruciate ligament and medial collateral ligament injury is likely so
the patient should be referred for MRI
C. Isolated medial meniscal tear could account for all his symptoms but anterior cruciate
and medial collateral ligament injuries are possible and should be evaluated
D. One crutch is most effective carried on the side opposite to the injury
E. Prophylactic antibiotics should be given by the GP as a haemarthrosis is present
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39. Regarding long bone fractures which statement is true?

NORMAL LABORATORY REFERENCE RANGE VALUES

A. Anatomical reduction of midshaft fractures in children is essential for a satisfactory
clinical outcome Femur- always in adults, seldom in children FBC: Hb 13.5-18.0 g/dl (male), 11.5-16.0 g/dl (female); WCC 4.0-11.0 × 109/L;

B. Angular deformity in shaft fractures is often acceptable in young children due to their Platelets 150-400 × 109/L; MCV 76-96 fL; MCHC 30-36 g/dl.

capacity to remodel Inflammation,

repairing,
C. Fractures in children heal by a different mechanism to adult fractures
remodelling.
D. Internal fixation increases the risk of infection and is therefore not indicated in most SMAC: Na+ 135-145 mmol/L; K+ 3.5-5.0 mmol/L; Cl- 95-105 mmol/L; HCO3- 24-30 mmol/L;

intra-articular fractures Fasting glucose 4-6 mmol/L; Urea 2.5-6.7 mmol/L; Creatinine 44-80 μmol/L;

E. Vascular injury is a common complication of distal radial fractures eGFR >90ml/min; Calcium 2.12-2.65 mmol/L; Bilirubin 3-17 μmol/L; Albumin 35-50 g/L; GGT
6-42 U/L; AST 5-35 U/L; ALT 5-35 U/L; ALP 30-150 U/L.

40. A 20 year old patient complains of severe pain in her leg 6 hours following
ABG: pH 7.35-7.45; PaCO2 4.7-6.0 kPa; PaO2 >10.6 kPa; HCO3- 24-30 mmol/L; Base excess +/-
intramedullary nailing of a closed simple tibial fracture. The patient has severe
2 mmol/L; Lactate Arterial 0.6 – 1.8 mmol/L
pain on the anterolateral aspect of the leg on plantarflexing the hallux but normal
sensation and pulses. Which one of the following options is the most appropriate
management?

A. Elevate limb, apply ice and give opiate analgesia using a patient controlled pump Other: INR 1.0; Prothrombin time 10-14s; CRP <8 mg/L; Plasma osmolality 278-305

B. Evaluate pulses clinically and with doppler if necessary; if pulse disappears proceed to mosmol/kg; Urine osmolality 350-1000 mosmol/kg; Prostate specific antigen 0-3.5

emergency fasciotomy μg/ml; HbA1C 20-42 mmol/mol.

C. Perform an emergency open fasciotomy

D. Removal of the locking screw of the nail
E. Request pain team to perform a block for pain relief

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