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Old 10-13-2012
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Arrow Billy Step 1 Questions # 27

A 27-year-old woman experienced sudden severe abdominal pain. On physical examination, she had marked
abdominal tenderness and guarding. Laboratory studies showed serum glucose, 76 mg/dL; calcium, 12.2 mg/dL;
phosphorus, 2.6 mg/dL; creatinine, 1.1 mg/dL; and parathyroid hormone, 62 pg/mL (normal range 9 to 60 pg/mL). During
surgery, four enlarged parathyroid glands were found and excised, with reimplantation of one half of one gland. After the
surgery, her serum calcium concentration returned to normal. Three years later, she had an episode of upper
gastrointestinal hemorrhage. An endoscopy and biopsy specimen showed multiple benign gastric ulcerations. Abdominal
MRI indicated multiple 1- to 2-cm mass lesions in the pancreas. She underwent surgery, and multiple gastrinomas were
found. Two years later, she now has galactorrhea. Which of the following lesions is now most likely to be present?


□ (A) Medullary carcinoma of the thyroid
□ (B) Adrenal pheochromocytoma
□ (C) Small-cell anaplastic carcinoma of the lung
□ (D) Endometrial carcinoma
□ (E) Pituitary adenoma
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E. Pituitary adenoma.

its MEN 1. 3 Ps (parathyroid,pancreas and pituitary)
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yes, MEN 1----3 P's

e) pituitary adenoma
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E) pituitary adenoma
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MEN 1
Pituitary adenoma
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□ (E) Pituitary adenoma
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Correct Answer E is correct

This patient has multiple endocrine neoplasia (MEN) type I, also known as Wermer syndrome. (Remember the
“three Ps” in neoplasia or hyperplasia—pancreas, pituitary, and parathyroids.) Endometrial carcinomas can arise in
patients who have unopposed estrogen secretion, which can occur in estrogen-producing ovarian tumors. These are not
part of MEN I. Medullary carcinomas are part of MEN IIA or IIB. Small-cell carcinomas of the lung are known for various paraneoplastic syndromes, but not usually hypercalcemia. It also is doubtful that this patient would have lived 5 years with
a small-cell carcinoma. If her hypercalcemia had been a paraneoplastic syndrome, the parathyroid glands would not have
been enlarged, and the serum calcium level would not have returned to normal after surgery.
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