Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 44-year-old woman with a painless right neck mass

mksap
Conditions
April 15, 2017
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 44-year-old woman is evaluated for a 2-month history of a painless right neck mass. Medical history is unremarkable, and she takes no medications. She is a lifelong nonsmoker.

On physical examination, vital signs are normal. A 5-cm right anterior neck mass is palpated. The remainder of the examination is unremarkable.

An initial CT scan of the neck shows a 4.5-cm, partially necrotic, right-sided lymph node. Asymmetric thickening of the right base of the tongue is also seen. Subsequent laryngoscopy shows an ulcerated mass involving the right base of the tongue. Biopsy of the tongue mass identifies poorly differentiated invasive squamous cell carcinoma. PET/CT scans show no evidence of distant metastases.

Which of the following studies should be performed next?

A. Bone scan
B. Human papillomavirus immunohistochemistry testing
C. MRI of the brain
D. Right cervical lymph node biopsy

MKSAP Answer and Critique

The correct answer is B: Human papillomavirus immunohistochemistry testing.

The most appropriate study to perform next in this patient is p16 immunohistochemistry testing. Although most squamous cell carcinomas of the head and neck were previously thought to be related primarily to tobacco and alcohol exposure, very recently, the important causative role played by human papillomavirus (HPV) has been widely recognized. HPV infection has definitively been associated with squamous cell carcinoma of the cervix for some time, and currently, it is estimated that most oropharyngeal cancers in North America and Europe are also linked to this infection. Evidence of underlying HPV infection is identified by testing for p16, which is a viral protein found in cancers that arise as a result of HPV infection. Although identifying evidence of HPV infection does not yet influence treatment decision-making, it does provide very important information regarding prognosis. The cure rate for locally advanced cancers that are linked with HPV is markedly higher than for those not linked with this virus. Because of this difference, testing for HPV is now a widely accepted intervention for any patient diagnosed with squamous cell carcinoma of the head and neck, particularly for patients with an oropharyngeal primary tumor.

A bone scan has no role in the management of this patient, as PET/CT scans have already been done. In addition, she has no indications for underlying bone metastasis based on her history.

MRI of the brain is not indicated because occult central nervous system metastases are very rare in patients with head and neck cancer, and this patient has no clinical indication of underlying brain metastasis.

Biopsy of the enlarged right cervical lymph node would provide no additional information, as the diagnosis has already been established based on biopsy of the lesion at the base of the tongue. Furthermore, because the cervical lymph node is so markedly enlarged, biopsy is not needed to establish involvement.

Key Point

  • p16 immunohistochemistry testing to detect human papillomavirus is now a widely accepted standard-of-care intervention to help determine prognosis in patients with squamous cell carcinoma of the head and neck, particularly those with oropharyngeal primary tumors.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Successful doctors will find meaningful ways to use social media to engage patients and colleagues

April 14, 2017 Kevin 0
…
Next

Your physician is the everyday champion

April 15, 2017 Kevin 2
…

ADVERTISEMENT

Tagged as: Infectious Disease

Post navigation

< Previous Post
Successful doctors will find meaningful ways to use social media to engage patients and colleagues
Next Post >
Your physician is the everyday champion

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • 3 ways we’ve failed woman who breastfeed

    Joanna Buscemi, PhD
  • The Buffalo mass shooting and food deserts

    Divya Srinivasan and Tejas Sekhar
  • No mass shooting is “worse” than another mass shooting

    Martha Rosenberg

More in Conditions

  • Why PSA levels alone shouldn’t define your prostate cancer risk

    Martina Ambardjieva, MD, PhD
  • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

    Olumuyiwa Bamgbade, MD
  • America’s ER crisis: Why the system is collapsing from within

    Kristen Cline, BSN, RN
  • Why timing, not surgery, determines patient survival

    Michael Karch, MD
  • Why psychotherapy works and why psychotherapy fails

    Peggy A. Rothbaum, PhD
  • How oral health silently affects your heart, brain, and body

    Charles Reinertsen, DMD
  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Why point-of-care ultrasound belongs in every emergency department triage [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why PSA levels alone shouldn’t define your prostate cancer risk

      Martina Ambardjieva, MD, PhD | Conditions
    • How to handle chronically late patients in your medical practice

      Neil Baum, MD | Physician
    • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

      Olumuyiwa Bamgbade, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • Why medicine must evolve to support modern physicians

      Ryan Nadelson, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Why point-of-care ultrasound belongs in every emergency department triage [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why PSA levels alone shouldn’t define your prostate cancer risk

      Martina Ambardjieva, MD, PhD | Conditions
    • How to handle chronically late patients in your medical practice

      Neil Baum, MD | Physician
    • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

      Olumuyiwa Bamgbade, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • Why medicine must evolve to support modern physicians

      Ryan Nadelson, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...