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10. Pathology and Oncology MCQs

Practice Set 21 of 351

This practice set contains high-yield board review questions covering key concepts in 10. Pathology and Oncology. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 401

Topic: 10. Pathology and Oncology

Which one of the following statements about sarcoidosis is true?

. A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis
. Clubbing of the fingers is an early feature
. Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis
. Parenchymal lung disease is often accompanied by pleural effusion
. When hypercalcaemia manifests, it is usually resistant to steroid therapy

Correct Answer & Explanation

. A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis

Explanation

Correct Answer: A- A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis Explanation A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis Sarcoidosis is a systemic disorder of unknown cause. Its pathological hallmark is the non-caseating granuloma, which primarily affects the respiratory tract, skin, eye, heart, kidneys and liver. A tuberculin test is usually negative in chronic sarcoidosis, but most patients with sarcoidosis who develop tuberculosis become tuberculin- positive. This is suggestive but not an absolute indicator of active infection. Clubbing of the fingers is an early feature Clubbing of the fingers is an early feature is incorrect. Clubbing of the fingers is not a recognised feature of sarcoidosis. Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis is incorrect. Although liver biopsy reveals granulomatous involvement in 40– 70% of patients, clinically significant hepatic disease is rare. Parenchymal lung disease is often accompanied by pleural effusion Parenchymal lung disease is often accompanied by pleural effusion is incorrect. Pleural disease is relatively infrequent, with effusions occurring in fewer than 5% of patients. When hypercalcaemia manifests, it is usually resistant to steroid therapy When hypercalcaemia manifests, it is usually resistant to steroid therapy is incorrect. Hypercalcaemia, a potentially important complication of sarcoidosis, occurs in fewer than 10% of patients and is thought to be owing to elevated levels of 1,25-dihydroxyvitamin D (calcitriol), which is produced by macrophages within the granulomas. High-dose glucocorticoids are very helpful in vitamin D intoxication, granulomatous diseases such as sarcoidosis, and haematological malignancies known to be or likely to be glucocorticoid- responsive.

Question 402

Topic: 10. Pathology and Oncology

A 28-year-old male presents with a slow-growing, painful mass near his knee joint. Biopsy reveals a biphasic spindle cell neoplasm. Which of the following chromosomal translocations is highly specific for this diagnosis?

. t(11;22)
. t(X;18)
. t(9;22)
. t(12;16)
. t(2;13)

Correct Answer & Explanation

. t(X;18)

Explanation

Synovial sarcoma is characterized by the t(X;18) chromosomal translocation, resulting in the SYT-SSX fusion gene. It commonly presents in young adults as a slow-growing mass near a large joint and is classically described as having a biphasic histology.

Question 403

Topic: 10. Pathology and Oncology

A 14-year-old girl is diagnosed with high-grade intramedullary osteosarcoma of the distal femur. Following neoadjuvant chemotherapy, she undergoes wide surgical resection. Which of the following histologic findings in the resected specimen is the most important prognostic indicator of long-term survival?

. Presence of distinct Codman's triangles on microscopic margins
. Percentage of tumor necrosis greater than 90%
. A high ratio of osteoblastic to chondroblastic cells
. Evidence of prominent perivascular lymphocytic infiltration
. Absence of skip metastases in the local muscle compartment

Correct Answer & Explanation

. Percentage of tumor necrosis greater than 90%

Explanation

The histologic response to neoadjuvant chemotherapy is the single most important prognostic factor in classic osteosarcoma. A good response is defined as greater than 90% tumor necrosis in the resected specimen, which correlates strongly with improved overall survival.

Question 404

Topic: 10. Pathology and Oncology

A 15-year-old boy is diagnosed with a conventional high-grade intramedullary osteosarcoma of the distal femur. He completes neoadjuvant chemotherapy and undergoes surgical resection. Pathological evaluation of the resected specimen reveals 95% tumor necrosis. What is the most significant prognostic indicator for this patient's long-term survival?

. The specific chemotherapeutic agents used
. The presence of "skip" lesions at presentation
. The percentage of tumor necrosis post-neoadjuvant chemotherapy
. The histologic subtype of the osteosarcoma
. The use of a limb-salvage procedure vs amputation

Correct Answer & Explanation

. The percentage of tumor necrosis post-neoadjuvant chemotherapy

Explanation

The degree of tumor necrosis following neoadjuvant chemotherapy (specifically >90%) is the most significant prognostic factor for long-term survival in conventional osteosarcoma. This histological response predicts both local recurrence and overall survival.

Question 405

Topic: 10. Pathology and Oncology

A 12-year-old boy presents with a painful mid-diaphyseal femur lesion with an "onion-skin" periosteal reaction. A biopsy is consistent with Ewing sarcoma. Which chromosomal translocation is most characteristically associated with this tumor?

. t(11;22)
. t(9;22)
. t(12;16)
. t(X;18)
. t(2;13)

Correct Answer & Explanation

. t(11;22)

Explanation

Ewing sarcoma is classically associated with the t(11;22)(q24;q12) translocation, which results in the EWS-FLI1 fusion gene. This molecular marker is highly sensitive and specific for tumors in the Ewing sarcoma family.

Question 406

Topic: 10. Pathology and Oncology

A 15-year-old male presents with distal femur pain. Plain radiographs show an aggressive, ill-defined lytic lesion in the metaphysis with a "sunburst" periosteal reaction and a Codman's triangle. After initial laboratory tests, what is the most appropriate next step in the local staging of this lesion?

. Open incisional biopsy
. CT scan of the chest
. MRI of the entire affected femur
. Technetium-99m bone scan
. Fine needle aspiration (FNA) in the outpatient clinic

Correct Answer & Explanation

. MRI of the entire affected femur

Explanation

Before a biopsy is performed, local staging must be completed. MRI of the entire involved bone is required to evaluate the soft tissue extent, neurovascular involvement, and the presence of any intramedullary skip lesions.

Question 407

Topic: 10. Pathology and Oncology

A 15-year-old girl presents with knee pain and a mixed lytic-blastic lesion with a "sunburst" periosteal reaction in the distal femur. Biopsy confirms high-grade intramedullary osteosarcoma. What is the standard sequence of management?

. Primary amputation followed by radiation
. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy
. Wide surgical resection followed by radiation therapy
. Primary radiation therapy and adjuvant chemotherapy
. Curettage, bone grafting, and adjuvant chemotherapy

Correct Answer & Explanation

. Neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy

Explanation

The standard of care for high-grade osteosarcoma involves neoadjuvant chemotherapy, followed by wide surgical resection (limb salvage or amputation), and subsequent adjuvant chemotherapy. This approach treats micrometastatic disease early and allows assessment of tumor necrosis.

Question 408

Topic: 10. Pathology and Oncology

Which of the following is most likely to preclude curative lobectomy for lung carcinoma?

. Forced expiratory volume in 1 s (FEV1) of 1.6 l
. Hypercalcaemia
. Local invasion by primary tumour through the chest wall
. Malignant pleural effusions
. Mediastinal lymph nodes enlarged on computed tomography (CT)

Correct Answer & Explanation

. Malignant pleural effusions

Explanation

Correct Answer: D- Malignant pleural effusions Explanation Malignant pleural effusions A malignant pleural effusion usually implies widely disseminated disease and any treatment is therefore often palliative. Forced expiratory volume in 1 s (FEV1) of 1.6 l Forced expiratory volume in 1 s (FEV1) of 1.6 l is incorrect. A forced expiratory volume in 1 s (FEV1) of over 1.5 l suggests that the patient has sufficient lung function to undergo an operation of this nature, but many of these patients will have considerable cardiorespiratory co-morbidity and a rigorous preoperative assessment is always required. Hypercalcaemia Hypercalcaemia is incorrect. Hypercalcaemia could be due to invasion of bone by the tumour, but this is not necessarily so; malignant cells in the lung tumour can produce humoral mediators which lead to an increase in the serum calcium level. Local invasion by primary tumour through the chest wall Local invasion by primary tumour through the chest wall is incorrect. Local invasion by the primary tumour through the chest wall is not in itself a reason why curative surgery should not be attempted, depending on the precise anatomy involved. Mediastinal lymph nodes enlarged on computed tomography (CT) Mediastinal lymph nodes enlarged on computed tomography is incorrect. The appearance of enlarged mediastinal lymph nodes on CT is suggestive of malignant spread but does not confirm it, thus this option is incorrect. A mediastinoscopy or biopsy guided by endobronchial ultrasound should be performed to confirm any enlarged nodes were malignant and if contralateral mediastinal nodes are confirmed malignant (ie N3 disease) then surgery would be contraindicated.

Question 409

Topic: 10. Pathology and Oncology
A 60-year-old woman attends the clinic complaining of shortness of breath over the preceding 2 months. She has also had problems with nasal irritation, discharge, and sinus pain. She is known to have asthma, which has recently been poorly controlled, despite inhaled steroids. Her full blood count has shown an eosinophilia of 13% and her chest X-ray shows peripheral pulmonary shadows. What is the most likely diagnosis?
. Allergic bronchopulmonary aspergillosis
. Cryptogenic organising pneumonia
. Eosinophilic granulomatosis with polyangiitis
. Granulomatosis with polyangiitis
. Severe asthma

Correct Answer & Explanation

. Eosinophilic granulomatosis with polyangiitis

Explanation

Correct Answer: C- Eosinophilic granulomatosis with polyangiitis. Eosinophilic granulomatosis with polyangiitis is an eosinophilic granulomatous inflammation of the respiratory tract with small- and medium-vessel necrotising vasculitis. It is diagnosed on finding four out of the following: asthma, blood eosinophilia > 10%, vasculitic neuropathy, pulmonary infiltrates, sinus disease, and extravascular eosinophils on biopsy. Allergic bronchopulmonary aspergillosis (ABPA) is incorrect; ABPA is a condition in which people with asthma have a vigorous IgE response to Aspergillus, with associated eosinophilia, a positive skin prick test to Aspergillus, and flitting consolidation on the chest X-ray, but no associated sinus disease. Cryptogenic organising pneumonia and Granulomatosis with polyangiitis are not typically associated with eosinophilia. Severe asthma is incorrect as the eosinophil count is higher than expected for asthma alone, and the abnormal chest radiograph suggests an alternative diagnosis.

Question 410

Topic: 10. Pathology and Oncology

A 50-year-old woman is admitted with a dry cough, shortness of breath and a 2-week history of intermittent fevers. She had flu-like symptoms at the beginning of her illness. On examination she has right-sided crepitations and a chest X-ray shows patchy shadowing at her right lower lobe, with an air bronchogram. Her white cell count and C-reactive protein (CRP) are raised. She is started on antibiotics for community-acquired pneumonia, improves clinically and is discharged after 2 days. You see her in clinic 3 months later, when she tells you that she is no better. Her chest X-ray shows left upper-lobe consolidation. What is the most likely cause of this?

. Cryptogenic organising pneumonia
. Eosinophilic pneumonia
. Lymphangioleiomyomatosis
. Pulmonary alveolar proteinosis
. Recurrent bacterial pneumonia

Correct Answer & Explanation

. Cryptogenic organising pneumonia

Explanation

Correct Answer: A- Cryptogenic organising pneumonia Explanation Cryptogenic organising pneumonia Cryptogenic organising pneumonia is a non-specific inflammatory pulmonary process, with buds of granulation tissue forming in the distal air spaces. Organising pneumonia can have a number of causes, including connective tissue disease, infection and drugs, but if there is no obvious cause it is called ‘cryptogenic’. It causes non-specific symptoms of fever, dry cough, malaise, anorexia and weight loss. Treatment is with steroids. Relapse is common, with further consolidation, and patients might need treatment with increased steroid doses. It is associated with raised a white cell count and C-reactive protein (CRP) levels. The chest X-ray can show consolidation, nodules or thickened septal lines. The consolidation typically occurs in different places at different times. Computed tomography (CT) findings are characteristic, with multiple patchy alveolar opacities, which often spontaneously migrate. The diagnosis might be made on the basis of CT alone, or on transbronchial or open lung biopsy. Eosinophilic pneumonia Eosinophilic pneumonia is incorrect. Acute eosinophilic pneumonia can present with cough, dyspnea, myalgia, fever and chest pain. Chest radiograph shows flitting peripheral infiltrates. Peripheral eosinophilia would likely be seen in acute eosinophilic pneumonia, which is not mentioned here. Lymphangioleiomyomatosis Lymphangioleiomyomatosis is incorrect. Lymphangioleiomyomatosis is a rare disease affecting women of childbearing age, who have abnormal proliferation of atypical smooth muscle cells throughout their lungs and airways – CT shows multiple small cysts. Cystic destruction of the lungs occurs and respiratory failure eventually develops. The condition is associated with the presence of abdominal tumours (eg angiomyolipomas and lymphangioleiomyomas). Pulmonary alveolar proteinosis Pulmonary alveolar proteinosis is incorrect. Pulmonary alveolar proteinosis is a rare defect in which the alveoli become filled with proteinaceous material that cannot be cleared. It usually presents between 30 and 50 years of age (unless congenital, which accounts for 10% of cases). Onset is often insidious, over several months to years. Patients typically present with a dry cough and breathlessness. Chest radiograh typically shows symmetrical perihilar and lower lobe consolidation. CT shows air-space shadowing, classically with a ‘crazy paving’ appearance due to interlobular septal thickening. Recurrent bacterial pneumonia Recurrent bacterial pneumonia is incorrect. Recurrent lobar bacterial infection is unusual in an immunocompetent adult.

Question 411

Topic: 10. Pathology and Oncology

Which of the following is the most important prognostic factor for long-term survival in a patient with a high-grade intramedullary osteosarcoma following neoadjuvant chemotherapy and wide surgical resection?

. Pre-operative tumor volume
. Tumor grade
. Histologic response to chemotherapy
. Specific anatomical location
. Patient age at diagnosis

Correct Answer & Explanation

. Histologic response to chemotherapy

Explanation

The percentage of tumor necrosis, or histologic response, following neoadjuvant chemotherapy is the single most important prognostic factor for overall survival in osteosarcoma. Greater than 90% necrosis indicates a favorable prognosis.

Question 412

Topic: 10. Pathology and Oncology

A 60-year-old woman with metastatic breast cancer presents with a lytic lesion in the mid-diaphysis of her femur. The lesion occupies 50% of the cortical diameter. She reports moderate pain with weight-bearing. What is her Mirels' score, and what does it recommend?

. Score 7: Radiation therapy only
. Score 8: Observation
. Score 9: Prophylactic internal fixation
. Score 10: Prophylactic internal fixation
. Score 11: Amputation

Correct Answer & Explanation

. Score 10: Prophylactic internal fixation

Explanation

Site: Lower extremity (2), Pain: Moderate (3), Lesion: Lytic (3), Size: 1/3-2/3 cortex (2). Total score = 10. A Mirels' score of 9 or greater is a strong indication for prophylactic internal fixation to prevent impending pathologic fracture.

Question 413

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with a destructive lesion of the distal femur highly suspicious for osteosarcoma. When performing an incisional biopsy of this lesion, which of the following oncologic principles is most critical to follow?

. Use a transverse incision to match Langer's lines for a better cosmetic outcome
. Ensure the biopsy tract is routed through an adjacent, uninvolved compartment
. Place a longitudinal incision directly in line with the planned definitive resection tract
. Elevate a large skin flap to adequately visualize the neurovascular structures
. Enter the lesion through an internervous plane to minimize muscle damage

Correct Answer & Explanation

. Place a longitudinal incision directly in line with the planned definitive resection tract

Explanation

Biopsy incisions for suspected musculoskeletal sarcomas must be longitudinal and placed directly within the planned surgical approach for definitive resection. This ensures that the entire biopsy tract, which is considered contaminated with tumor cells, can be excised en bloc.

Question 414

Topic: 10. Pathology and Oncology

A 15-year-old male presents with severe right thigh pain. Radiographs reveal a permeative diaphyseal lesion with an "onion-skin" periosteal reaction. A biopsy shows small round blue cells. What genetic translocation is most commonly associated with this diagnosis?

. t(11;22)
. t(9;22)
. t(X;18)
. t(2;13)
. t(12;16)

Correct Answer & Explanation

. t(11;22)

Explanation

Ewing sarcoma is characterized by small round blue cells and an "onion-skin" periosteal reaction. The t(11;22) translocation, resulting in the EWS-FLI1 fusion protein, is found in approximately 85% of these cases.

Question 415

Topic: 10. Pathology and Oncology

A 75-year-old male with a history of prostate cancer presents with progressively worsening back pain and bilateral leg weakness. MRI of the thoracic spine shows a large epidural metastatic mass causing severe spinal cord compression at T8. He has been non-ambulatory for 24 hours. What is the best initial definitive treatment?

. Intravenous dexamethasone and emergent surgical decompression
. Emergent radiotherapy alone
. Hormonal therapy
. Chemotherapy
. Observation

Correct Answer & Explanation

. Intravenous dexamethasone and emergent surgical decompression

Explanation

For acute malignant spinal cord compression causing an active neurologic deficit, high-dose IV dexamethasone should be started immediately. Emergent surgical decompression followed by radiation is the standard of care for solid tumors causing cord compression with acute decline.

Question 416

Topic: 10. Pathology and Oncology

A 15-year-old boy presents with knee pain. Radiographs show a sunburst periosteal reaction in the distal femur. Biopsy confirms high-grade osteosarcoma. Which of the following is the most significant prognostic factor for survival in this patient?

. Histological subtype (osteoblastic vs. chondroblastic)
. Patient age at presentation
. Size of the primary tumor
. Percentage of tumor necrosis following neoadjuvant chemotherapy
. Presence of a Codman triangle on imaging

Correct Answer & Explanation

. Percentage of tumor necrosis following neoadjuvant chemotherapy

Explanation

The histologic response to neoadjuvant chemotherapy, defined as the percentage of tumor necrosis at the time of definitive resection, is the single most important prognostic factor for long-term survival in high-grade osteosarcoma.

Question 417

Topic: 10. Pathology and Oncology

A 50-year-old lawyer attended a clinic with a 15-day history of dyspnoea and weight loss over the past 6 months. He reports his sputum to be clear. On examination, a diagnosis of pleural effusion was made that was confirmed on chest X-ray. A pleural tap revealed few red cells and lymphocytes and a protein level of 40 g/l. What should be the next investigative step?

. Bronchoscopy
. Computed tomography of the thorax
. Percutaneous pleural biopsy
. Sputum examination for tubercle bacilli
. Thoracoscopic pleural biopsy

Correct Answer & Explanation

. Computed tomography of the thorax

Explanation

Correct Answer: B- Computed tomography of the thorax Explanation Computed tomography of the thorax BTS guidelines from 2010 recommend contrast computed tomography (CT) as the most appropriate nextinvestigation here. Bronchoscopy Bronchoscopy is incorrect. Bronchoscopy would only be indicated if investigations such as contrast CT and pleural biopsy were non-diagnostic and a lung mass amenable to bronchoscopic sampling was seen on CT. Percutaneous pleural biopsy Percutaneous pleural biopsy is incorrect. Pleural biopsy would be indicated following CT using radiological guidance, under local anaesthetic thoracoscopy or via a video-assisted thoracoscopic surgery (VATS). ‘Blind’ percutaneous pleural biopsies are essentially obsolete now, given their poor diagnostic yield. Sputum examination for tubercle bacilli Sputum examination for tubercle bacilli is incorrect. It is justifiable to test sputum for tuberculosis in this case, but this is not a history highly suggestive of TB and the next most appropriate investigation is CT. Thoracoscopic pleural biopsy Thoracoscopic pleural biopsy is incorrect. A thoracoscopic pleural biopsy allows the physician to perform directed pleural biopsies, remove the pleural fluid and carry out pleurodesis to prevent recurrence.

Question 418

Topic: 10. Pathology and Oncology
A 60-year-old man presents to the emergency department as a GP referral. He has had a non-productive niggling cough over the past few weeks, and most recently severe headaches and swelling of his face and arms. He smokes 20 cigarettes per day and has done so for 40 years. Examination reveals a blood pressure of 155/85 mmHg; you notice dilated veins over his arms and upper chest, his face looks plethoric, and there is evidence of edema. Auscultation of the chest reveals poor air entry and wheeze consistent with COPD. Investigations: Hb 13.8 g/dl, WCC 9.9 × 10^9/l, PLT 188 × 10^9/l, Na+ 137 mmol/l, K+ 4.5 mmol/l, Creatinine 112 μmol/l, CXR Large right hilar mass, CT scan Right hilar mass suspicious of bronchial carcinoma, leading to SVC compression. Which of the following is the most appropriate intervention?
. Chemotherapy
. Corticosteroids
. Radiotherapy
. Stenting
. Surgical bypass

Correct Answer & Explanation

. Stenting

Explanation

This patient has Superior Vena Cava (SVC) obstruction as a result of extrinsic compression from an underlying bronchial carcinoma. A NICE review has concluded that stenting offers a greater degree of success in terms of relief of symptoms than radiotherapy, and is therefore the intervention of choice here.

Question 419

Topic: 10. Pathology and Oncology

Which one of the following features is most accurate regarding Pneumocystis jirovecii pneumonia (PJP)?

. Auscultation of the lungs usually reveals no abnormality
. Blood culture is positive in a third of cases
. Metronidazole is the treatment of choice
. Occurs exclusively in people with AIDS
. Pleural effusion is frequently bilateral

Correct Answer & Explanation

. Auscultation of the lungs usually reveals no abnormality

Explanation

Correct Answer: A- Auscultation of the lungs usually reveals no abnormality Explanation Auscultation of the lungs usually reveals no abnormality Pneumocystis jirovecii pneumonia (PJP) is a pulmonary disease characterised by dyspnoea, tachypnoea and hypoxaemia. On examination patients usually show signs of respiratory distress (tachypnoea, dyspnoea). Auscultation of the lung usually reveals no abnormalities. Blood culture is positive in a third of cases Blood culture is positive in a third of cases is incorrect. The trophozoite does not enter the blood; the organism is identified in pulmonary secretions. Previously diagnosis relied on bronchoalveolar lavage or lung biopsy and staining with methenamine silver or Giemsa stain. Now the diagnsosis is usually made by PCR of sputum of bronchoalveolar lavage fluid. Metronidazole is the treatment of choice Metronidazole is the treatment of choice is incorrect. Co- trimoxazole is the recommended treatment; alternatively, pentamidine isethionate can be used. Metronidazole is not effective in the treatment of PJP. Occurs exclusively in people with AIDS Occurs exclusively in people with AIDS is incorrect. P. jirovecii pneumonia occurs in patients who are deficient in immunoglobulin G (IgG) and IgM and in patients deficient in cell-mediated immunity. The vast majority of adult patients with this pneumonia have AIDS, but it can also occur in patients who have received chemotherapy for a haematological malignancy or after an organ transplant. It can also occur in malnourished or premature infants. Pleural effusion is frequently bilateral Pleural effusion is frequently bilateral is incorrect. Pleural effusions are uncommon in PJP, occurring in < 5% cases. Where they are present they are usually unilateral.

Question 420

Topic: 10. Pathology and Oncology

Which is the most common malignant tumour found in the lung?

. Adenocarcinoma of the bronchus
. Carcinoid tumour
. Metastatic carcinoma
. Oat-cell carcinoma
. Squamous-cell carcinoma of the bronchus

Correct Answer & Explanation

. Metastatic carcinoma

Explanation

Correct Answer: C- Metastatic carcinoma Explanation Metastatic carcinoma Malignant metastases to the lung can present as a solitary enlarging nodule, as multiple nodules or with diffuse lymphatic involvement. Solitary metastasis represents some 10% of round lesions in general, but some 70% of round lesions in patients with a known malignancy. Colorectal cancer is reported to be the most common tumour of origin. A diagnosis can usually be secured by percutaneous computed tomography- (CT-) guided biopsy. In rare cases, surgical excision prolongs survival or results in cure, depending on the state of the primary tumour and the likelihood of other occult metastases. In general, the longer the interval between resection of the primary tumour and the appearance of the metastases, the better is the prognosis. Multiple metastases range enormously in size and number, from cannon balls to miliary shadowing, and can be accompanied by hilar lymphadenopathy or pleural effusion. Breast, colon, renal and lung primaries are probably the most common underlying tumours, but other tumours amenable to chemotherapy (eg testicular cancer, choriocarcinoma) and sarcomas also metastasise in this way. A diagnosis might be made on the basis of cytology or histology on various samples from the pleura or lung and can occasionally be made from cytology on expectoration or induced sputum. It is particularly important to accurately identify tumours that are suitable for chemotherapy or for endocrine manipulation (eg breast). Solitary or multiple Kaposi’s sarcoma is a feature of AIDS, and can involve the bronchi and pleura as well as lung tissue. Lymphangitis carcinomatosa is most commonly due to breast and primary lung tumours (usually adenocarcinomas). Patients can be asymptomatic when the disease is first suspected on the basis of an X-ray showing diffusely increased interstitial markings accompanied by Kerley B lines, hilar lymphadenopathy or pleural effusion.Although the diagnosis can be established by cytology from sputum or pleural fluid, it often requires a bronchoscopic or transbronchial lung biopsy. Later, progressive and severe breathlessness with hypoxaemia often develops, and patients require vigorous palliative relief with opiates and oxygen. Metastases are sometimes confined to a bronchus and will not be visible on a plain chest X-ray – diagnosis requires bronchoscopy. These metastases tend to present with haemoptysis, which can usually be effectively controlled by radiotherapy. Renal carcinoma and malignant melanoma are recorded causes. Adenocarcinoma of the bronchus Adenocarcinoma of the bronchus is incorrect. Metastatic carcinoma is the most common malignant tumour found in the lung. Carcinoid tumour Carcinoid tumour is incorrect. Metastatic carcinoma is the most common malignant tumour found in the lung. Oat-cell carcinoma Oat-cell carcinoma is incorrect. Metastatic carcinoma is the most common malignant tumour found in the lung. Squamous-cell carcinoma of the bronchus Squamous-cell carcinoma of the bronchus is incorrect. Metastatic carcinoma is the most common malingnant tumour found in the lung.

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