ITE Pulmonology 5 — Questions and Answers
Question 1: A 52-year-old male with a history of deep vein thrombosis presents with exertional dyspnea 18 months after a PE. V/Q scan shows multiple segmental mismatched defects. mPAP on RHC is 32 mmHg with PVR of 5 Wood units. What is the best treatment option?
- Lifelong anticoagulation alone
- Pulmonary endarterectomy (PEA) (Correct answer)
- Balloon pulmonary angioplasty (BPA)
- Bosentan
Correct answer: Pulmonary endarterectomy (PEA)
Chronic thromboembolic pulmonary hypertension (CTEPH) with surgically accessible proximal lesions is best treated with pulmonary endarterectomy, which is potentially curative.
Question 2: A 60-year-old male with long-standing GERD and Barrett's esophagus develops a dry cough and progressive dyspnea. HRCT shows basal-predominant reticulation with traction bronchiectasis and honeycombing. The BAL shows 6% lymphocytes. What is the most likely diagnosis?
- Hypersensitivity pneumonitis
- Idiopathic pulmonary fibrosis (IPF) (Correct answer)
- NSIP associated with GERD
- Cryptogenic organizing pneumonia
Correct answer: Idiopathic pulmonary fibrosis (IPF)
The HRCT pattern of bibasilar honeycombing with traction bronchiectasis represents UIP pattern, most consistent with IPF, even in the context of GERD; low BAL lymphocytes also favor IPF over HP.
Question 3: A 25-year-old male with cystic fibrosis has FEV1 that has declined from 65% to 42% over 2 years despite optimal inhaled therapy. He has the F508del/F508del genotype. Which CFTR modulator regimen is most appropriate?
- Ivacaftor alone
- Lumacaftor-ivacaftor
- Elexacaftor-tezacaftor-ivacaftor (Trikafta) (Correct answer)
- Ataluren
Correct answer: Elexacaftor-tezacaftor-ivacaftor (Trikafta)
Elexacaftor-tezacaftor-ivacaftor (Trikafta) is approved for F508del homozygous patients age ≥2 and produces the greatest improvement in lung function of any available CFTR modulator combination.
Question 4: A 72-year-old male with COPD and FEV1 30% predicted is evaluated for lung volume reduction surgery (LVRS). Which finding would make him an IDEAL candidate for LVRS?
- Homogeneous emphysema on CT with DLCO <20%
- Upper-lobe predominant emphysema with low exercise capacity (Correct answer)
- FEV1 <20% predicted with homogeneous disease
- Alpha-1 antitrypsin deficiency with lower-lobe predominant emphysema
Correct answer: Upper-lobe predominant emphysema with low exercise capacity
The NETT trial showed survival benefit for LVRS in patients with upper-lobe predominant emphysema and low exercise capacity; homogeneous disease with FEV1/DLCO <20% showed excess mortality.
Question 5: A 44-year-old female never-smoker develops cough and hemoptysis. Bronchoscopy reveals a polypoid endobronchial lesion in the right lower lobe. Biopsy shows carcinoid features with 3 mitoses/10 HPF and focal necrosis. What is the diagnosis?
- Typical carcinoid tumor
- Atypical carcinoid tumor (Correct answer)
- Large cell neuroendocrine carcinoma
- Small cell lung carcinoma
Correct answer: Atypical carcinoid tumor
Atypical carcinoid is defined by 2–10 mitoses/10 HPF and/or foci of necrosis, distinguishing it from typical carcinoid (<2 mitoses/10 HPF, no necrosis); both differ from high-grade neuroendocrine tumors.
Question 6: A 38-year-old male returns from a camping trip in the Ohio River Valley with fever, night sweats, and a hilar mass on CXR. Serum LDH is mildly elevated. Urine Histoplasma antigen is positive. What is the most appropriate treatment?
- Observation — self-limited illness
- Itraconazole for 12 weeks (Correct answer)
- Amphotericin B liposomal formulation
- Fluconazole
Correct answer: Itraconazole for 12 weeks
Mild-to-moderate pulmonary histoplasmosis with symptoms >4 weeks (chronic or subacute) is treated with itraconazole for 6–12 weeks; amphotericin B is reserved for severe or disseminated disease.
Question 7: A 55-year-old male with newly diagnosed small cell lung cancer has disease confined to the right hemithorax and ipsilateral mediastinal nodes that can be encompassed in a radiation field. What is the classification and treatment approach?
- Extensive-stage SCLC — chemotherapy alone
- Limited-stage SCLC — concurrent chemoradiation (Correct answer)
- Limited-stage SCLC — surgery followed by chemotherapy
- Extensive-stage SCLC — chemo + immunotherapy
Correct answer: Limited-stage SCLC — concurrent chemoradiation
Limited-stage SCLC (confined to one hemithorax within a tolerable radiation field) is treated with concurrent platinum-based chemotherapy and thoracic radiation, with prophylactic cranial irradiation if response is achieved.
ITE Pulmonology 5
A 52-year-old male with a history of deep vein thrombosis presents with exertional dyspnea 18 months after a PE.
V/Q scan shows multiple segmental mismatched defects. mPAP on RHC is 32 mmHg with PVR of 5 Wood units.
What is the best treatment option?