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Continuing Medical Education Exam 5: June 2006
GASTROENTEROLOGY 2006;130:2208 –2209
CME ACTIVITY Continuing Medical Education Exam 5: June 2006 CME Credits: The American Gastroenterological Association Institute (AGA Institute) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AGA Institute designates these educational activities for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activities.
Faculty Disclosure: In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support of Continuing Medical Education, all faculty and planning partners must disclose any financial relationship(s) or other relationship(s) held within the past 12 months. All disclosures have been evaluated for potential commercial bias and, if identified, relevant conflicts of interest were resolved.
Instructions: Category 1 credit can be earned by reading the relevant articles and taking these CME examinations online at http:// www.gastrojournal.org/content/cme.
Objectives: Upon completion of these activities, participants should be able to demonstrate an increase in or affirmation of their knowledge of clinical medicine and evaluate the appropriateness of the clinical information as it applies to the provision of patient care.
Exam 5: American Gastroenterological Association Institute Technical Review on the Management of Gastric Subepithelial Masses Hwang JH, Rulyak SD, Kimmey MB, Authors Test ID No. gast0026
Contact hours: 2.0
Expiration Date: June 30, 2007
Question 1: A 45-year-old man is evaluated with upper endoscopy for symptoms of dyspepsia and is found to have a 3-cm mass in the gastric antrum with normal-appearing overlying mucosa. Biopsy specimens are obtained with a standard forceps and show normal gastric mucosa. EUS demonstrates a hypoechoic lesion arising from the fourth EUS layer with homogenous echotexture. What is the most appropriate next step in patient management?
a. Repeat EGD in 1 year. b. Repeat EUS in 1 year. c. Perform EUS-guided fine needle aspiration (EUS-FNA) or core biopsy. d. Perform endoscopic submucosal resection (ESMR). e. No further work-up necessary.
Question 2: A 60-year-old woman has a known subepithelial mass (normal mucosal biopsies in the past) and has been followed with annual EGD examinations for the past 2 years by another gastroenterologist. According to the patient’s gastroenterologist, the lesion appears to have enlarged over the past year. She remains asymptomatic. She is now referred for EUS evaluation of the subepithelial lesion. On EUS examination, the lesion is located in the gastric antrum, 3 cm in diameter, well demarcated, intensely hyperechoic, and arising from the third EUS layer. What is the most appropriate next step?
a. b. c. d. e.
Proceed with surgical resection. Continue with yearly EGD examination. Repeat EUS examination in 1 year. No further evaluation needed in the absence of symptoms. Perform EUS-guided fine needle aspiration or core biopsy.
June 2006
2209
Question 3: A 69-year-old woman is referred for EUS evaluation of a gastric subepithelial mass. Mucosal biopsies demonstrate normal gastric mucosa. On endoscopic examination, the lesion is located in the gastric body. When probed with closed biopsy forceps, the lesion is firm, slightly mobile, and does not exhibit a pillow sign. The estimated size is 2 cm using open biopsy forceps as a reference. EUS examination reveals a hypoechoic third layer lesion with regular appearing margins. Which of the following is not in the differential diagnosis?
a. b. c. d. e.
Carcinoid tumor. Lipoma. Pancreatic rest. Glomus tumor. Metastatic carcinoma.
Question 4: A previously healthy 53-year-old executive is admitted to the hospital with melena. EGD is performed and reveals a 5-cm subepithelial mass in the gastric body with a central ulcer but no active bleeding. Endoscopic ultrasound (EUS) reveals a 5.6-cm hypoechoic mass arising from the muscularis propria consistent with a gastrointestinal stromal tumor (GIST). What is the most appropriate management strategy?
a. Therapy with a proton pump inhibitor and repeat EGD in 6 – 8 weeks. b. CT scan of the abdomen and referral for surgical resection. c. Referral to a medical oncologist for chemotherapy with imatinib mesylate (Gleevec). d. Repeat EUS in 1 year to confirm stability of the lesion. e. Endoscopic resection of the lesion as an outpatient.
Question 5: A 68-year-old woman is found to have an incidental 2.5-cm mass arising in the gastric fundus on upper endoscopy, and mucosal biopsies are positive for carcinoid tumor. Random biopsies of the antrum and fundus are normal. Gastric pH at the time of EGD is 2.0 and a serum gastrin level is normal. What is the appropriate management strategy?
a. Reassurance and follow-up with her primary care provider. b. Referral for EUS and endoscopic submucosal resection. c. Initiation of a proton pump inhibitor and repeat EGD in 6 months. d. Referral for surgical resection. e. Evaluation for gastrinoma associated with multiple endocrine neoplasia Type I (MEN-1).
Question 6: An otherwise healthy 50-year-old man with longstanding gastroesophageal reflux disease undergoes EGD to screen for Barrett’s esophagus. He is found to have an incidental 1.5-cm, yellowish mass in the gastric fundus. Endoscopic ultrasonography with a catheter probe reveals a hyperechoic, well-circumscribed mass arising in echo layer 3 (submucosa). What would you recommend?
a. b. c. d. e.
Reassurance and follow-up with his primary care provider. Fine-needle aspiration to determine the diagnosis. Stacked forceps biopsy to determine the diagnosis. Endoscopic submucosal resection. Repeat EUS in 1 year for surveillance.
CME ACTIVITY Continuing Medical Education Exam 5: June 2006 CME Credits: The American Gastroenterological Association Institute (AGA Institute) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AGA Institute designates these educational activities for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activities.
Faculty Disclosure: In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support of Continuing Medical Education, all faculty and planning partners must disclose any financial relationship(s) or other relationship(s) held within the past 12 months. All disclosures have been evaluated for potential commercial bias and, if identified, relevant conflicts of interest were resolved.
Instructions: Category 1 credit can be earned by reading the relevant articles and taking these CME examinations online at http:// www.gastrojournal.org/content/cme.
Objectives: Upon completion of these activities, participants should be able to demonstrate an increase in or affirmation of their knowledge of clinical medicine and evaluate the appropriateness of the clinical information as it applies to the provision of patient care.
Exam 5: American Gastroenterological Association Institute Technical Review on the Management of Gastric Subepithelial Masses Hwang JH, Rulyak SD, Kimmey MB, Authors Test ID No. gast0026
Contact hours: 2.0
Expiration Date: June 30, 2007
Question 1: A 45-year-old man is evaluated with upper endoscopy for symptoms of dyspepsia and is found to have a 3-cm mass in the gastric antrum with normal-appearing overlying mucosa. Biopsy specimens are obtained with a standard forceps and show normal gastric mucosa. EUS demonstrates a hypoechoic lesion arising from the fourth EUS layer with homogenous echotexture. What is the most appropriate next step in patient management?
a. Repeat EGD in 1 year. b. Repeat EUS in 1 year. c. Perform EUS-guided fine needle aspiration (EUS-FNA) or core biopsy. d. Perform endoscopic submucosal resection (ESMR). e. No further work-up necessary.
Question 2: A 60-year-old woman has a known subepithelial mass (normal mucosal biopsies in the past) and has been followed with annual EGD examinations for the past 2 years by another gastroenterologist. According to the patient’s gastroenterologist, the lesion appears to have enlarged over the past year. She remains asymptomatic. She is now referred for EUS evaluation of the subepithelial lesion. On EUS examination, the lesion is located in the gastric antrum, 3 cm in diameter, well demarcated, intensely hyperechoic, and arising from the third EUS layer. What is the most appropriate next step?
a. b. c. d. e.
Proceed with surgical resection. Continue with yearly EGD examination. Repeat EUS examination in 1 year. No further evaluation needed in the absence of symptoms. Perform EUS-guided fine needle aspiration or core biopsy.
June 2006
2209
Question 3: A 69-year-old woman is referred for EUS evaluation of a gastric subepithelial mass. Mucosal biopsies demonstrate normal gastric mucosa. On endoscopic examination, the lesion is located in the gastric body. When probed with closed biopsy forceps, the lesion is firm, slightly mobile, and does not exhibit a pillow sign. The estimated size is 2 cm using open biopsy forceps as a reference. EUS examination reveals a hypoechoic third layer lesion with regular appearing margins. Which of the following is not in the differential diagnosis?
a. b. c. d. e.
Carcinoid tumor. Lipoma. Pancreatic rest. Glomus tumor. Metastatic carcinoma.
Question 4: A previously healthy 53-year-old executive is admitted to the hospital with melena. EGD is performed and reveals a 5-cm subepithelial mass in the gastric body with a central ulcer but no active bleeding. Endoscopic ultrasound (EUS) reveals a 5.6-cm hypoechoic mass arising from the muscularis propria consistent with a gastrointestinal stromal tumor (GIST). What is the most appropriate management strategy?
a. Therapy with a proton pump inhibitor and repeat EGD in 6 – 8 weeks. b. CT scan of the abdomen and referral for surgical resection. c. Referral to a medical oncologist for chemotherapy with imatinib mesylate (Gleevec). d. Repeat EUS in 1 year to confirm stability of the lesion. e. Endoscopic resection of the lesion as an outpatient.
Question 5: A 68-year-old woman is found to have an incidental 2.5-cm mass arising in the gastric fundus on upper endoscopy, and mucosal biopsies are positive for carcinoid tumor. Random biopsies of the antrum and fundus are normal. Gastric pH at the time of EGD is 2.0 and a serum gastrin level is normal. What is the appropriate management strategy?
a. Reassurance and follow-up with her primary care provider. b. Referral for EUS and endoscopic submucosal resection. c. Initiation of a proton pump inhibitor and repeat EGD in 6 months. d. Referral for surgical resection. e. Evaluation for gastrinoma associated with multiple endocrine neoplasia Type I (MEN-1).
Question 6: An otherwise healthy 50-year-old man with longstanding gastroesophageal reflux disease undergoes EGD to screen for Barrett’s esophagus. He is found to have an incidental 1.5-cm, yellowish mass in the gastric fundus. Endoscopic ultrasonography with a catheter probe reveals a hyperechoic, well-circumscribed mass arising in echo layer 3 (submucosa). What would you recommend?
a. b. c. d. e.
Reassurance and follow-up with his primary care provider. Fine-needle aspiration to determine the diagnosis. Stacked forceps biopsy to determine the diagnosis. Endoscopic submucosal resection. Repeat EUS in 1 year for surveillance.