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NBME 17 Answers

nbme17/Block 0/Question#0 (reveal difficulty score)
A 70-year-old man dies in a motor vehicle ...
Tubular adenoma 🔍 / 📺 / 🌳 / 📖

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submitted by waitingonprometric(264)
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From FA2020, pg. 381:

Tubular adenoma--> neoplastic; tubular histology has less malignant potential than villous; tubulovillous has intermediate malignant potential; usually asymptomatic, may present with rectal bleeding. Hence our patient who has been undergoing evaluation for fecal occult blood.

Other answers:

Hyperplastic polyp--> most common, generally smaller and in rectosigmoid region. I'm guessing the picture attached to this question is trying to clue us into this not being a small lesion.

Inflammatory pseudopolyps--> due to mucosal erosion in inflammatory bowel disease. There is no appreciable erosions in this picture, also the mass appears pedunculated, so we know it's not a spot of normal mucosa that just looks raised compared to surrounding erosion.

Juvenile polyp and Peutz-Jeghers syndrome--> these are both genetic disorders with numerous hamartomatous polyps seen in the colon. Peutz-Jeghers also associated with increased risk of breast and other GI cancers. It is unlikely that our patient had either of these b/c he is 70 y/o; therefore, if he had one of these, he would likely have more than one colon lesion and may also present with a history of other cancers at his age.

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cheesetouch  great refutation of others, thanks! +3
lpp06  To add - tubular adenomas are pedunculate masses, as seen in the image +2
soccerfan23  great explanation and username lol +
sexymexican888  Also... idk if this helps but it got me the right answer (plus clinical scenario) : golijan said TUBULAR ADENOMA -> STRAWBERRY ON A STICK I know thats for the histology but idk thats what it looked like to me haha +1
kcyanide101  I got this question because of Goljian!!!!!!!!! STRAWBERRY ON A STICK :) +

 +2  upvote downvote
submitted by aoa05(34)
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This is a solitary mushroom like growth in the colon so by definition it is a polyp and since it is in the colon then adenomatous/tubular polyp would be the most common. The patient is 70 years old therefore he is too old to have Peutz-Jeghers syndrome and this is a solitary polyp while PJ is multiple juvenile polyposis therefore there should be many polyps in the image. The vast majority of juvenile polyps occur in children younger than 5 years of age but they can present at older ages as well. Most juvenile polyps are located in the rectum and typically present with rectal bleeding. We are not give a history of prior polyps so this is an incidental polyp in an older man. Inflammatory pseudopolyps occur in a background of injury such as ulcerative colitis and here we are not given that history and the background colonic  is normal. Hyperplastic polyps are most commonly found in 6th and 7th decade-like this patient-  in the left colon and are typically less than 5 mm in diameter. They are smooth, nodular protrusions of the mucosa.

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