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Old 04-26-2012
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Question Back pain and Weight loss!

A 46-year-old woman is evaluated in the office for a 6-month history of increasing back pain, fatigue, and an 11-kg (25-lb) weight loss from baseline. She does not smoke cigarettes. The remainder of her medical history is noncontributory, and her family history is unremarkable.

On physical examination, there is bone tenderness in the midthoracic spine and the right anterior sixth rib. The remainder of the examination, including evaluation of the pelvis and breasts, is normal.

Laboratory studies include a hemoglobin of 11.1 g/dL with a mean corpuscular volume of 92 fL. Results of mammography are normal. A CT scan of the chest, abdomen, and pelvis is unremarkable except for bone abnormalities; a bone scan reveals multiple areas of increased radioisotope uptake in the lumbar and thoracic spine and in multiple ribs. A poorly differentiated tumor is identified by needle biopsy of a large sixth rib lesion.

Which of the following is the most appropriate next diagnostic step?
A Breast biopsy
B Colonoscopy
C Immunohistochemical staining of the tumor biopsy specimen
D Positron emission tomography
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Old 04-26-2012
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A Breast biopsy
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Quote:
Originally Posted by dryogi View Post
A Breast biopsy
Where are you going to put your needle?
Results of mammography are normal
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In future, i must avoid to reply questions while I'm sleepy
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Old 04-26-2012
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Quote:
Originally Posted by dryogi View Post
In future, i must avoid to reply questions while I'm sleepy
Don't worry I am not NBME...go ahead ...knock yourself out..sleepy or not
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Old 04-26-2012
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-is't C..angiosarcoma?!
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Old 04-26-2012
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Quote:
Originally Posted by usmledee View Post
A 46-year-old woman is evaluated in the office for a 6-month history of increasing back pain, fatigue, and an 11-kg (25-lb) weight loss from baseline. She does not smoke cigarettes. The remainder of her medical history is noncontributory, and her family history is unremarkable.

On physical examination, there is bone tenderness in the midthoracic spine and the right anterior sixth rib. The remainder of the examination, including evaluation of the pelvis and breasts, is normal.

Laboratory studies include a hemoglobin of 11.1 g/dL with a mean corpuscular volume of 92 fL. Results of mammography are normal. A CT scan of the chest, abdomen, and pelvis is unremarkable except for bone abnormalities; a bone scan reveals multiple areas of increased radioisotope uptake in the lumbar and thoracic spine and in multiple ribs. A poorly differentiated tumor is identified by needle biopsy of a large sixth rib lesion.

Which of the following is the most appropriate next diagnostic step?
A Breast biopsy
B Colonoscopy
C Immunohistochemical staining of the tumor biopsy specimen
D Positron emission tomography
There is nothing to suspect a Breast or Colonic pathology.

PET scan is excellent for detecting the occult metastasis BUT not vice versa.

So, the only possibility is C.

Quote:
IHC is an excellent detection technique and has the tremendous advantage of being able to show exactly where a given protein is located within the tissue examined. It is also an effective way to examine the tissues .This has made it a widely used technique in the neurosciences, enabling researchers to examine protein expression within specific brain structures. Its major disadvantage is that, unlike immunoblotting techniques where staining is checked against a molecular weight ladder, it is impossible to show in IHC that the staining corresponds with the protein of interest. For this reason, primary antibodies must be well-validated in a Western Blot or similar procedure. The technique is even more widely used in diagnostic surgical pathology for typing tumors (e.g. immunostaining for e-cadherin to differentiate between DCIS (ductal carcinoma in situ: stains positive) and LCIS (lobular carcinoma in situ: does not stain positive)[2]).
http://en.wikipedia.org/wiki/Immunohistochemistry

http://en.wikipedia.org/wiki/Positro...ion_tomography
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Correct Answer = C

In patients with adenocarcinoma of an unknown primary site, the workup should be guided by the patient's history and physical and laboratory findings. In this patient, immunohistochemical staining of the tumor for the presence of the HER2-Neu oncogene and estrogen and progesterone receptor expression (i.e., tumor markers for breast cancer) may be useful in making therapeutic decisions.

Colonoscopy would be indicated in this patient only if her history or physical or laboratory findings suggest the likelihood for the colon as the primary site and immunohistochemical staining and hormone receptor expression tests were not helpful.

In small trials, positron emission tomography has been found to detect the source of cancer in 20% to 30% of patients with an unknown primary site; however, larger trials are needed to confirm these results and demonstrate the usefulness of this detection method in various clinical scenarios. A breast biopsy should not be performed in this patient because there are no radiographic or physical findings suggestive of a breast primary tumor.

Key Point
In women with adenocarcinoma of unknown primary site, immunohistochemical staining of the tumor for the presence of the HER2-Neu oncogene and estrogen and progesterone receptor expression may be useful in making therapeutic decisions.
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Old 04-27-2012
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C Immunohistochemical staining of the tumor biopsy specimen

As other examinations are normal so other options are ruled out. PET is done to see if metastatic lesions are active or not. So answer should be c...
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