Internal-Medicine

Answers: 8–24 131
with HD. Other components of staging include
CBC, lytes, LDH, CXR, and bone marrow
biopsy. PET and gallium scanning are not
always done, and are usually helpful at the
completion of treatment to document remission.
The purpose of staging laparotomy is to
determine whether radiation alone will be used
for treatment. As chemotherapy usage increases,
the necessity for staging laparotomy decreases.
(Kasper, pp. 654–655)
18. (C) The most characteristic presentation of
Hodgkin’s disease is that of enlarged, superficial
cervical or supraclavicular lymph nodes in a
young person. The nodes are usually freely
moveable, nontender, and not painful. Occult
presentation with intrathoracic or intraabdominal
disease is unusual. (Kasper, pp. 654–655)
19. (C) About 85% of low-grade lymphocytic lymphomas
are widespread at the time of diagnosis.
However, staging is still important as radiation
therapy can be curative for localized (stage I, II)
disease. Because the prognosis for this malignancy
is measured in years, it has been difficult
to demonstrate a survival benefit for aggressive
chemotherapy. The poor prognosis for lymphoma
in older patients might be a result of
less-aggressive therapy. (Kasper, pp. 648–649)
20. (B) Cutaneous lymphomas are of T-cell origin
and are more common in other parts of the
world, such as Japan. Patients with adult T-cell
lymphoma-leukemia (ATLL) have acute fulminant
courses characterized by skin invasion and
leukemic cells. This syndrome is clearly related
to human T-cell lymphotropic virus-I (HTLV-I),
and there is a possibility that HTLV-I, or another
retrovirus, might be the agent for mycosis fungoides
and Sézary syndrome. ATLL responds
poorly to treatment and therapy for the lowgrade
malignancies controls symptoms but
does not result in cure. (Kasper, p. 653)
21. (B) Age, history of smoking, and polycythemia
in a patient with hematuria strongly suggests a
renal cell carcinoma. The elevated hemoglobin
represents increased erythropoietin production
and is not related to prognosis. Involvement
along the renal vein and metastases to the lung
is also characteristic of renal cell carcinoma.
Elevated liver enzymes and weight loss can
represent nonmetastatic effects of malignancy
and can reverse with resection. Almost half of
patients will have a palpable abdominal mass
on presentation. The CT of the thorax is a
useful test because three-quarters of those with
metastatic disease will have lung metastases.
(Kasper, pp. 541–542)
22. (D) Breast-conserving surgery is now recommended
for small tumors. Radiation therapy
will decrease local recurrence rates. For tumors