NYACP Board Review Question of the Week

Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam.  Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.

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June 16th, 2026

MKSAP 19 Oncology, Question 55

A 66-year-old woman is evaluated following completion of therapy for locally advanced squamous cell carcinoma of the hypopharynx. She was treated with combined cisplatin chemotherapy and irradiation. One month ago, imaging with PET/CT revealed a complete response. She is a former smoker with a 40-pack-year history who quit 7 years ago. She takes no medications.

On physical examination, vital signs are normal. She has dry oral mucosa and post-irradiation induration to the right of the neck. No cervical adenopathy is noted.

Which of the following imaging tests is most appropriate?

A.    Low-dose CT of the chest in 1 year
B.    MRI of the neck in 3 months
C.    PET/CT in 3 months
D.    No additional imaging is required

Responses Received from Members (Graph is uploaded on Thursday afternoon):

The Correct Answer is: A. Low-dose CT of the chest in 1 year

Educational Objective: Screen for lung cancer in a former smoker diagnosed with head and neck cancer.

This patient should have a low-dose CT of the chest in 1 year (Option A). She was diagnosed with locally advanced hypopharynx cancer. As is common in this type of cancer, treatment with combined chemotherapy and irradiation was recommended. She completed this treatment and achieved complete remission. Surveillance for recurrence is now indicated. Standard surveillance consists of physical examination and assessment for symptoms suggestive of recurrence. Physical examination includes in-office laryngoscopy to evaluate the upper aerodigestive tract for both local recurrence and development of second primary cancers. Following an imaging study identifying no active disease after completion of treatment, further imaging studies for surveillance purposes are not indicated. Such testing has not been shown to improve outcomes. Rather, imaging to look for recurrence is based on clinical suspicion of recurrence as directed by signs and symptoms. However, patients diagnosed with head and neck cancer are at risk for second cancers, most notably non–small cell lung cancer. This is especially true in patients aged 50 to 80 years who are current smokers or have quit less than 15 years ago and who have at least a 20-pack-year smoking history. All patients who meet criteria for lung cancer screening should be offered screening with a low-dose CT on an annual basis.

PET/CT (Option C) is not indicated in this patient for surveillance purposes because it does not improve outcomes. The same is true for MRI of the neck (Option B). Advanced imaging is reserved for patients with signs or symptoms suggestive of recurrence.

Up to 20% of head and neck cancer survivors develop a second primary cancer related to smoking and alcohol exposure. In addition to lifestyle modification, screening for lung cancer should be implemented in individuals at increased risk, rather than no additional imaging (Option D).

Key Point

• Following an imaging study identifying no active disease after completion of treatment for head and neck cancer, further imaging studies for surveillance purposes are not indicated.
• Patients with head and neck cancer, especially current or former smokers, should be screened for lung cancer.

Bibliography

Chow LQM. Head and neck cancer. N Engl J Med. 2020;382:60-72. PMID: 31893516 doi:10.1056/NEJMra1715715

Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.

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June 2nd, 2026

MKSAP 19 Infectious Disease, Question 101

A 38-year-old woman is hospitalized for fever, night sweats, and a nonproductive cough of 6 weeks' duration. Medical history is significant for Crohn disease. Her only medication is ustekinumab.
On physical examination, temperature is 39.6 °C (103.3 °F), blood pressure is 100/60 mm Hg, pulse rate is 120/min, and respiration rate is 26/min. Crackles are heard in both lung fields. Abdominal examination reveals no hepatosplenomegaly.

Laboratory studies:    
Hemoglobin    10 g/dL (100 g/L)
Leukocyte count    3600/µL (3.6 × 109/L)
Platelet count    109,000/µL (109 × 109/L)
Alkaline phosphatase    312 U/L
Alanine aminotransferase    51 U/L
Aspartate aminotransferase    58 U/L

Serum and urinary Histoplasma antigen are negative. Interferon-γ release assay is negative. Chest radiograph is shown.

Which of the following is the most likely diagnosis?

A.    Disseminated histoplasmosis
B.    Disseminated tuberculosis
C.    Streptococcus pneumoniae bacteremia
D.    Subacute hypersensitivity pneumonia

Responses Received from Members (638 Responses):

The Correct Answer is: B. Disseminated tuberculosis

Educational Objective: Diagnose disseminated tuberculosis infection.

The most likely diagnosis is disseminated tuberculosis infection (Option B). This patient's use of a biologic immune modifier (ustekinumab) is a significant risk factor for tuberculosis reactivation or dissemination. The patient's interferon-γ release assay was negative, but anergy is observed more frequently among patients with miliary tuberculosis than those with pulmonary or isolated extrapulmonary involvement. Disseminated tuberculosis often involves the lungs, liver, and bone marrow. The patient's chest radiograph reveals the bilateral presence of innumerable 1- to 3-mm nodules. These findings, although not specific, are typical of tuberculosis dissemination through the vasculature or the lymphatic vessels. She also has pancytopenia, an indication of bone marrow involvement, and increased alkaline phosphatase and aminotransferase levels indicate hepatic involvement. Finally, her high fever, increased heart rate and respiration rate, and hypotension are also signs of sepsis. Although not usually in the differential diagnosis, disseminated tuberculosis can induce classic septic shock and death if not diagnosed and treated promptly and adequately.

Sepsis, pancytopenia, oral ulcerations, and hepatosplenomegaly in an immunosuppressed patient are typical of disseminated histoplasmosis (Option A). However, the Histoplasma serum and urinary antigen were negative; these tests have a sensitivity and specificity approaching 80% in immunosuppressed patients with disseminated infection, making this diagnosis less likely.

The triad of pneumococcal endocarditis, meningitis, and pneumonia (Austrian syndrome) is the result of Streptococcus pneumoniae bacteremia (Option C). However, this is an acute and rapidly progressive disease and is not compatible with this patient's 6-week course of progressive illness.

Repetitive inhalation of antigens in a sensitized patient can result in hypersensitivity pneumonitis (HP) (Option D). Patients with subacute HP have a chronic low-level exposure to antigens and experience cough, fatigue, weight loss, and shortness of breath. High-resolution CT will show micronodules and ground-glass opacities. Subacute HP does not involve the bone marrow or liver or result in sepsis.

Key Point

• Immunosuppression is a risk factor for disseminated tuberculosis, which often involves the lungs, liver, and bone marrow and may result in systemic inflammatory response syndrome, septic shock, and death.
• The interferon-γ release assay may be negative in patients with disseminated tuberculosis.
  

Bibliography

Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.

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Last Updated:  6.12.26