DETAILED VERIFIED SOLUTIONS|GRADED A+|NEWEST 2026/2027
A 13-year old female presents to the office complaining of a painful mass right above her
buttocks. She says that sometimes "water-looking stuff" drains out of the mass. On exam,
the patient has a large quantity of hair, and you observe a fluctuant mass in the
sacrococcygeal region. How would you explain your findings to the patient? - ANSWER
The patient has pilonidal disease which typically manifests around puberty. During puberty
when the sweat and oil glands become more active, the hair follicles get large and inflamed
and end up bursting into the surrounding tissue which forms a pilonidal abscess/sinus. Loose
hairs then get sucked into the pilonidal sinus when the person moves and because the hairs
are trapped, it results in a infection/foreign body reaction.
When performing surgery for pilonidal disease, where should the drainage incision be
placed and why? - ANSWER Away from midline (lateral to the tract/cyst) because
incisions do not heal well in the intergluteal natal cleft due to increased friction
What are the advantages and disadvantages for the preferred treatment of pilonidal cysts? -
ANSWER Preferred treatment is incision and drainage of the cyst, removal of the hair,
and packing of the cavity with gauze. Advantage: simple procedure done under a local.
Disadvantage: requires frequent packing changes until the cyst heals (usually 3 weeks).
What medical treatments and education would you offer the previously mentioned patient
(pilonidal disease)? - ANSWER Sterilization and removal of hair from the sinus tract with
phenol injections followed by curettage. The patient should also be given paraffin jelly to
protect the skin and should be encouraged to bathe regularly and keep the area shaved.
Describe marsupialization and the advantages and disadvantages (in regards to pilonidal
disease). - ANSWER A procedure that involves I & D, removal of pus/hair, followed by
sewing the edges of the fibrous tract to the wound edges to make a pouch. Advantages:
outpatient surgery under a local; small wound; no need to pack the wound with gauze.
Disadvantages: requires 6 weeks to heal; requires physician trained in the technique.
1
,A 57-year old male presents to the office complaining of decreased stool caliber. He says that
he eats a lot of meat, fatty foods, and alcohol. He said that occasionally there's a little bit of
blood on his stool. Physical exam is unremarkable, and the FOBT is positive. Which imaging
modality would be the most appropriate for further evaluation? - ANSWER Colonoscopy
to detect polyps (and to rule out tumors/masses)
What are the histological differences between the various types of colonic polyps? -
ANSWER Adenomatous polyps (show signs of dysplasia)
1. tubular
2. villous
3. tubulovillous
Hyperplastic polyps (most common type of benign polyp)
Assuming the patient above desires surgical intervention, what options would you give him
(the man with colonic polyps)? - ANSWER 1. Polypectomy: useful for removing solitary
lesions that are larger in size
2. Colonic resection: (total colectomy, subtotal colectomy with rectal sparing, or segmental
resection) useful for cases of multiple intestinal polyps associated with FAP, or for patients
with UC who have high-grade dysplasia
How soon should a patient who had a colonic polyp removed return for repeat
colonoscopies? - ANSWER 5 years if the polyp only had low-risk features. 3 years if the
polyp had high-risk features. If the patient does not have any more polyps after the first
colonoscopy, they should return every 5 years.
How often should patients with HNPCC (hereditary nonpolyposis colorectal cancer) receive
colonoscopies and why? - ANSWER Every 1-2 years because progression to cancer is
more rapid due to the genetic instability of the lesions.
What are the two most common types of bladder cancers and where do almost all bladder
cancers originate? - ANSWER Transitional cell carcinoma and squamous cell carcinoma.
Almost all bladder cancers originate in the urothelium which is a mucosal layer within the
muscular bladder.
2
,A 68-year old white male presents to the office with complaints of urinating blood. He
denies any pain or other associated symptoms. Physical exam is normal. Which studies
would you want to include in your evaluation of this patient and why? - ANSWER CBC:
look for elevated WBC count (may indicate infection - UTI) or presence of anemia
Liver Function Tests: to evaluate liver function (for baseline for possible treatment and also
to see if there is evidence of metastasis)
Urine Analysis: looking for RBCs in the urine (in men, shouldn't have any)
Cytoscopy: primary modality for evaluating for bladder cancer. Allows clinician to obtain
biopsy specimens and resect papillary tumors.
CT urography/ultrasonagraphy to evaluate for upper urinary tract tumors
What is the TNM staging system for bladder cancer? - ANSWER Staging is as follows:
CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium
Ta - Papillary tumor confined to the epithelium
T1 - Tumor invasion into the lamina propria
T2 - Tumor invasion into the muscularis propria
T3 - Tumor involvement of the perivesical fat
T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall
N+ - Lymph node metastasis
M+ - Metastasis
What is the first-line treatment to diagnose, stage, and treat visible tumors that are not
carcinoma in situ? What are the indications for radical cystectomy? - ANSWER TURBT -
transurethral resection of bladder tumor - which is done endoscopically. Radical
cystectomies are typically indicated when the disease has invaded the muscle, or when it is
high-risk.
What is the standard chemotherapeutic treatment for metastatic bladder cancer? Which
regimen offers a less toxic option? - ANSWER MVAC: Methotrexate, Vinblastine,
Doxorubincin (Adriamycin), and Cisplatin
3
, Less toxic regimen: Gemcitabine and cisplatin
What are the standard treatments available for clinically localized prostate cancer? -
ANSWER Active surveillance, radical prostectomy, radiation therapy with or without
androgen therapy, or cryotherapy. There are multiple forms of radiation therapy available
including conventional, 3-dimensional conformal radiotherapy, intensity-modulated
radiotherapy, and brachytherapy (where the radiation source is placed inside or next to the
prostate).
A 53-yearl old African American man presents to your office with complaints of difficulty
urinating, frequency, and lower back and leg pain. On examination, you note that the
prostate is irregularly enlarged and firm. What is the initial workup for this patient, and in
which patients may additional studies be indicated before surgical intervention can be
attempted? - ANSWER Initial workup: DRE, PSA, and biopsy. More comprehensive studies
prior to surgery may be indicated in patients with a PSA > 10, high-grade histology, and/or
physical exam findings that suggest a T3 stage or higher, due to their increased risk for
metastatic disease.
Name and describe the method for staging prostate cancer. - ANSWER Called the Gleason
Score. A score of 1-5 is assigned to the most common type of tissue pattern, and the same is
done for the second most common type. The two scores are added together to obtain the
Gleason score. Patterns are assigned as follows:
Pattern 1 - closely resembles normal prostate tissue; glands are small, well-formed, and
closely packed.
Pattern 2 - the tissue still has well-formed glands, but they are larger and have more tissue
between them.
Pattern 3 - The tissue still has recognizable glands, but the cells are darker. At high
magnification, some of these cells are beginning to invade the surrounding tissue.
Pattern 4 - The tissue has few recognizable glands. Many cells are invading the surrounding
tissue
Pattern 5 - The tissue does not have recognizable glands.
4
A 13-year old female presents to the office complaining of a painful mass right above her
buttocks. She says that sometimes "water-looking stuff" drains out of the mass. On exam,
the patient has a large quantity of hair, and you observe a fluctuant mass in the
sacrococcygeal region. How would you explain your findings to the patient? - ANSWER
The patient has pilonidal disease which typically manifests around puberty. During puberty
when the sweat and oil glands become more active, the hair follicles get large and inflamed
and end up bursting into the surrounding tissue which forms a pilonidal abscess/sinus. Loose
hairs then get sucked into the pilonidal sinus when the person moves and because the hairs
are trapped, it results in a infection/foreign body reaction.
When performing surgery for pilonidal disease, where should the drainage incision be
placed and why? - ANSWER Away from midline (lateral to the tract/cyst) because
incisions do not heal well in the intergluteal natal cleft due to increased friction
What are the advantages and disadvantages for the preferred treatment of pilonidal cysts? -
ANSWER Preferred treatment is incision and drainage of the cyst, removal of the hair,
and packing of the cavity with gauze. Advantage: simple procedure done under a local.
Disadvantage: requires frequent packing changes until the cyst heals (usually 3 weeks).
What medical treatments and education would you offer the previously mentioned patient
(pilonidal disease)? - ANSWER Sterilization and removal of hair from the sinus tract with
phenol injections followed by curettage. The patient should also be given paraffin jelly to
protect the skin and should be encouraged to bathe regularly and keep the area shaved.
Describe marsupialization and the advantages and disadvantages (in regards to pilonidal
disease). - ANSWER A procedure that involves I & D, removal of pus/hair, followed by
sewing the edges of the fibrous tract to the wound edges to make a pouch. Advantages:
outpatient surgery under a local; small wound; no need to pack the wound with gauze.
Disadvantages: requires 6 weeks to heal; requires physician trained in the technique.
1
,A 57-year old male presents to the office complaining of decreased stool caliber. He says that
he eats a lot of meat, fatty foods, and alcohol. He said that occasionally there's a little bit of
blood on his stool. Physical exam is unremarkable, and the FOBT is positive. Which imaging
modality would be the most appropriate for further evaluation? - ANSWER Colonoscopy
to detect polyps (and to rule out tumors/masses)
What are the histological differences between the various types of colonic polyps? -
ANSWER Adenomatous polyps (show signs of dysplasia)
1. tubular
2. villous
3. tubulovillous
Hyperplastic polyps (most common type of benign polyp)
Assuming the patient above desires surgical intervention, what options would you give him
(the man with colonic polyps)? - ANSWER 1. Polypectomy: useful for removing solitary
lesions that are larger in size
2. Colonic resection: (total colectomy, subtotal colectomy with rectal sparing, or segmental
resection) useful for cases of multiple intestinal polyps associated with FAP, or for patients
with UC who have high-grade dysplasia
How soon should a patient who had a colonic polyp removed return for repeat
colonoscopies? - ANSWER 5 years if the polyp only had low-risk features. 3 years if the
polyp had high-risk features. If the patient does not have any more polyps after the first
colonoscopy, they should return every 5 years.
How often should patients with HNPCC (hereditary nonpolyposis colorectal cancer) receive
colonoscopies and why? - ANSWER Every 1-2 years because progression to cancer is
more rapid due to the genetic instability of the lesions.
What are the two most common types of bladder cancers and where do almost all bladder
cancers originate? - ANSWER Transitional cell carcinoma and squamous cell carcinoma.
Almost all bladder cancers originate in the urothelium which is a mucosal layer within the
muscular bladder.
2
,A 68-year old white male presents to the office with complaints of urinating blood. He
denies any pain or other associated symptoms. Physical exam is normal. Which studies
would you want to include in your evaluation of this patient and why? - ANSWER CBC:
look for elevated WBC count (may indicate infection - UTI) or presence of anemia
Liver Function Tests: to evaluate liver function (for baseline for possible treatment and also
to see if there is evidence of metastasis)
Urine Analysis: looking for RBCs in the urine (in men, shouldn't have any)
Cytoscopy: primary modality for evaluating for bladder cancer. Allows clinician to obtain
biopsy specimens and resect papillary tumors.
CT urography/ultrasonagraphy to evaluate for upper urinary tract tumors
What is the TNM staging system for bladder cancer? - ANSWER Staging is as follows:
CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium
Ta - Papillary tumor confined to the epithelium
T1 - Tumor invasion into the lamina propria
T2 - Tumor invasion into the muscularis propria
T3 - Tumor involvement of the perivesical fat
T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall
N+ - Lymph node metastasis
M+ - Metastasis
What is the first-line treatment to diagnose, stage, and treat visible tumors that are not
carcinoma in situ? What are the indications for radical cystectomy? - ANSWER TURBT -
transurethral resection of bladder tumor - which is done endoscopically. Radical
cystectomies are typically indicated when the disease has invaded the muscle, or when it is
high-risk.
What is the standard chemotherapeutic treatment for metastatic bladder cancer? Which
regimen offers a less toxic option? - ANSWER MVAC: Methotrexate, Vinblastine,
Doxorubincin (Adriamycin), and Cisplatin
3
, Less toxic regimen: Gemcitabine and cisplatin
What are the standard treatments available for clinically localized prostate cancer? -
ANSWER Active surveillance, radical prostectomy, radiation therapy with or without
androgen therapy, or cryotherapy. There are multiple forms of radiation therapy available
including conventional, 3-dimensional conformal radiotherapy, intensity-modulated
radiotherapy, and brachytherapy (where the radiation source is placed inside or next to the
prostate).
A 53-yearl old African American man presents to your office with complaints of difficulty
urinating, frequency, and lower back and leg pain. On examination, you note that the
prostate is irregularly enlarged and firm. What is the initial workup for this patient, and in
which patients may additional studies be indicated before surgical intervention can be
attempted? - ANSWER Initial workup: DRE, PSA, and biopsy. More comprehensive studies
prior to surgery may be indicated in patients with a PSA > 10, high-grade histology, and/or
physical exam findings that suggest a T3 stage or higher, due to their increased risk for
metastatic disease.
Name and describe the method for staging prostate cancer. - ANSWER Called the Gleason
Score. A score of 1-5 is assigned to the most common type of tissue pattern, and the same is
done for the second most common type. The two scores are added together to obtain the
Gleason score. Patterns are assigned as follows:
Pattern 1 - closely resembles normal prostate tissue; glands are small, well-formed, and
closely packed.
Pattern 2 - the tissue still has well-formed glands, but they are larger and have more tissue
between them.
Pattern 3 - The tissue still has recognizable glands, but the cells are darker. At high
magnification, some of these cells are beginning to invade the surrounding tissue.
Pattern 4 - The tissue has few recognizable glands. Many cells are invading the surrounding
tissue
Pattern 5 - The tissue does not have recognizable glands.
4
