Devita, Hellman, and Rosenberg's Cancer

LWBK1006-19 LWW-Govindan-Review December 7, 2011 21:24

Chapter 19•Neoplasms of the Mediastinum 219

Question 19.13. A 39-year-old woman presents with a cough and dyspnea that have pro-

gressed over the past 4 months. She is now dyspneic on walking less than

100 feet. Examination shows an anxious woman with a pulse of 110

beats/min, a respiratory rate of 24 breaths/min, and mild stridor. Lungs

are otherwise clear to auscultation, and heart sounds are regular. Chest

radiograph shows a large anterior mediastinal mass with narrowing of

the mid-trachea. CT scan shows a 10-cm, highly heterogeneous ante-

rior mediastinal mass with foci of dense calcification that compresses the

trachea and superior vena cava without obstruction. Laboratory studies

reveal normal blood counts, chemistries, LDH, carcinoembryonic antigen

(CEA),-fetoprotein, and-hCG. She undergoes complete resection of

the mass, which is adherent to the trachea, superior vena cava, left pleura,

and pericardium without gross invasion. Pathologic evaluation reveals a

multicystic mass with foci of mature gland formation, respiratory epithe-

lium, cartilage, and bone. There is no invasion into adjacent structures,

and surgical margins are negative. What is the most appropriate manage-

ment of this patient?

A. Clinical surveillance

B. Adjuvant radiotherapy

C. Cisplatin plus etoposide×four cycles

D. Doxorubicin plus ifosfamide×six cycles

Question 19.14. A 23-year-old man presents with hoarseness, cough, and anterior chest

pain. He has a 30 pack-year smoking history. Examination is normal.

Chest radiograph shows a large left mediastinal mass and clear lung fields.

CT scan of the chest shows a 5-cm irregular left paratracheal mass. CT

scan of the abdomen is normal. Serum CEA,-hCG, and-fetoprotein

are normal. Bronchoscopy reveals extrinsic compression of the left main-

stem bronchus without an endobronchial lesion. Left mediastinotomy

with biopsy of the anterior mediastinal mass reveals a poorly differen-

tiated malignant neoplasm that is immunohistochemically negative for

leukocyte common antigen, vimentin, S100, TTF1, and chromogranin,

but positive for low molecular weight cytokeratin. Genetic studies reveal

no B- or T-cell rearrangements, and karyotypic analysis shows aneuploidy

with an isochromosome 12p. Which of the following is the most appro-

priate therapy for this patient?

A. Cisplatin plus etoposide

B. Cisplatin, etoposide, and bleomycin

C. Concurrent chemotherapy and radiation therapy

D. Cyclophosphamide, doxorubicin, vincristine, and prednisone