A 64 year old man is found to have a nodular prostate on digital rectal examination. Subsequent biopsy confirms cancer of the prostate.
Which one of the following would have the most prognostic value?
Correct Answer D: Prognosis for prostate cancer involves the following main factors: Stage and Gleason grade or score. Stage: As with many other types of cancer, the outcome of prostate cancer depends on whether it has spread when it is diagnosed.
Gleason grade or score: With prostate cancer, the prognosis also depends on how the cells look under the microscope. This is called the grade of the cancer. In prostate cancer, this is recorded as the Gleason score. A Gleason score of 2, 3 or 4 indicates a low grade prostate cancer that is likely to grow very slowly. A Gleason score of 5, 6 or 7 is an intermediate grade that will grow at a moderate rate. A Gleason score of 8 to 10 is a high grade cancer that is likely to grow relatively fast.
A 64 year old man is brought to see you by his wife because of increasing memory problems and confusion over three months. He has become gradually more listless and apathetic, with a significant change in personality. She has noted that he has had increasing difficulty with recalling recent events. The patient does not complain of memory problems, but has complained of bilateral headache over the past two months. He has drunk four bottles of beer every day for twenty years, although his drinking has decreased over the last two months. His gait is slightly unsteady and wide-based.
What is the most likely diagnosis?
Correct Answer A: Chronic subdural hematomas are more common among alcoholics and among older people. Alcoholics, who are relatively prone to falls and other injuries, may ignore minor to moderately severe head injuries. These injuries can lead to small subdural hematomas that may become chronic. In older people, the brain shrinks slightly, stretching the bridging veins and making them more likely to be torn if an injury, even a minor one, occurs. Also, bleeding tends to continue longer because older people heal more slowly. After the blood is resorbed from a hematoma, the brain may not re-expand as well in older people as in younger people. As a result, a fluid-filled space (hygroma) may be left.
Symptoms may include a persistent headache, fluctuating drowsiness, confusion, memory changes, paralysis on the opposite side of the body, and other symptoms depending on which area of the brain is damaged. Chronic subdural hematomas are more difficult to diagnose because of the length of time between the injury and the development of symptoms. However, MRI or CT can detect chronic as well as acute subdural hematomas.
An 77-year-old man becomes "senile" over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell off his rocking chair about a week before the mental changes began.
Which of the following would a CT scan of his head most likely show?
Correct Answer B: People who are very old or alcoholic have smaller brains in a skull that has not changed in size; thus, very minimal trauma can make the brain "rattle around" and tear a venous sinus, from which a subdural hematoma very slowly forms. Senility does not occur in a 3 week period. Such marked changes in someone with recent trauma should trigger a search for chronic subdural hematoma.
A 30-year-old woman who has been taking oral contraceptive pills for many years presents for a complete physical examination. You palpate a small abdominal lump in her right upper quadrant.
A CT of the abdomen will most like show which of the following?
Correct Answer B: A hepatocellular adenoma is a relatively uncommon noncancerous liver tumor that may be mistaken for cancer. Rarely, it ruptures and bleeds or becomes cancerous. Hepatocellular adenomas occur mainly in women of childbearing age, particularly those who use oral contraceptives.
Usually, these tumors cause no symptoms, so most remain undetected. Large adenomas may cause pain in the upper right part of the abdomen. Rarely, a hepatocellular adenoma suddenly ruptures and bleeds into the abdominal cavity, requiring emergency surgery. Very rarely, these tumors become cancerous.
An adenoma is usually suspected when an imaging test, such as ultrasonography or computed tomography (CT), is done and shows an abnormality. Sometimes a biopsy is needed to confirm the diagnosis.
Hepatocellular adenomas caused by oral contraceptive use may disappear when the woman stops taking the drug. If adenomas are large or located near the surface of the liver, surgery is recommended because bleeding and cancer are risks.
A 51 year old man presents with symptoms consistent with hypercalcemia, which is confirmed with a high blood calcium measurement. Further imaging results show tumors in three different organs. A diagnoses of Wermer syndrome (MEN I) is made.
All of the following surgeries may be indicated in this patient, except:
Correct Answer D: Multiple endocrine neoplasia (MEN) has three sub-types, type I, type IIA and type IIB. Type I (Wermer syndrome) involves tumors of the ‘3 P’s - pituitary (prolactinoma), pancreas and parathyroid (causing elevated PTH levels and hypercalcemia). Type IIA (Sipple syndrome) involves tumors of the parathyroid, adrenal (pheochromocytoma) and thyroid (medullary carcinoma). Type IIB involves tumors of the adrenal, thyroid and mucosal neuromas.
Since this patient has been diagnosed with MEN I, he could have surgical removal of any or all of the tumors, which include parathyroidectomy, neurosurgery of the pituitary, removal of a prolactinoma or pancreatic surgery. A thyroidectomy would be considered in MEN IIA and IIB.
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