American Board of Internal Medicine (ABIM) Certification Practice Exam

What is indicated if local lymph node metastases are found after surgery in patients initially thought to be stage I?

1. Observation only

2. Postoperative chemotherapy and radiation therapy

3. Repeat surgery

4. Clinical trial enrollment

The correct answer is: Postoperative chemotherapy and radiation therapy

The presence of local lymph node metastases after surgery in patients initially classified as stage I indicates a more advanced stage of cancer than previously thought. The initial staging suggests that the malignancy was confined to its original site without lymphatic involvement. However, the discovery of lymph node metastases means that cancer has spread, typically leading to a reassessment of the patient's stage, likely moving them to stage II or higher. In such cases, postoperative chemotherapy and radiation therapy become critical components of the treatment strategy. These interventions are designed to eliminate any remaining cancer cells that may not have been removed during surgery and to reduce the risk of recurrence. The rationale behind systemic chemotherapy is to address potential micrometastatic disease that was not detected prior to surgery, particularly in lymphatic structures that serve as critical pathways for cancer dissemination. Other options like observation may leave the patient at risk for disease progression, while repeat surgery might not be effective if there are multiple or diffuse metastases. Lastly, clinical trial enrollment could be beneficial for some patients but is not a standard protocol for all cases and depends on various factors including study eligibility and patient preference. Thus, the appropriate course following the finding of lymph node metastases is a combination of postoperative chemotherapy and radiation therapy to achieve the best