Deck 3: Treatment Options for Different Cancer Cases

Question 1

A 47-year-old woman is recovering from surgery for stage III ovarian cancer (spread to the peritoneal cavity but without parenchymal liver involvement). Not all of the visible cancer could be resected; the largest residual tumor was 3 cm in diameter. Her performance status is excellent. She is interested in pursuing aggressive therapy and wishes to be treated as soon as possible in her local community. The proposed systemic therapy will involve cisplatin or carboplatin and paclitaxel. What further treatment is appropriate for this patient?

A)No further treatment beyond the proposed standard therapy
B)Another drug that has a different mechanism of action
C)Regional peritoneal therapy
D)High-dose therapy with peripheral or bone marrow stem cell rescue
E)A second-look laparotomy

Answer 1

No further treatment beyond the proposed standard therapy

Question 2

A 62-year-old postmenopausal woman with a family history of breast cancer in two first-degree relatives wishes to consider taking tamoxifen to reduce her risk of breast cancer. Her baseline risk of breast cancer qualifies her for consideration of tamoxifen (i.e., an absolute risk of at least 1.66% over the next 5 years). She has had a prior hysterectomy, but her ovaries are intact. Which of the following effects of tamoxifen are relevant to the decision?

A)Decreased risk of myocardial infarction or ischemic heart disease
B)Increased risk of deep venous thrombosis
C)Increased risk of ovarian cancer
D)Increased risk of major depression
E)Increased risk of colorectal cancer

Answer 2

Increased risk of deep venous thrombosis

Question 3

A 50-year-old perimenopausal woman is evaluated because of abdominal swelling. CT scan of the chest, abdomen, and pelvis shows mesenteric lymphadenopathy and a small amount of ascites but no ovarian masses. Needle biopsy specimen shows adenocarcinoma; the tumor is found to be negative for hormone receptors. The serum carcinoembryonic antigen level is normal at 2.0 ng/mL and the serum CA-125 is 1200 ng/mL (elevated). What is the best next step in her treatment?

A)Combination chemotherapy
B)Debulking surgery
C)Radiation therapy to a wide port
D)Positron emission tomography scan to assess other sites of disease
E)Bone scan to rule out skeletal metastases

Answer 3

Debulking surgery

Question 4

A 50-year-old menstruating woman has a 1 .5-cm moderately differentiated breast cancer. The lesion is completely excised, and the margins of the excision are negative. Axillary node sampling shows that she has three positive nodes. The tumor is negative for estrogen and progesterone receptors and is highly positive for HER2. She is otherwise healthy. Her mother had breast cancer at 62 years and was treated by mastectomy; she is alive and healthy at the age of 80 years. The patients sister had breast cancer at 54 years and was treated by breast conservation therapy; 4 years later she died of a recurrence of breast cancer. The patient has seen two different surgeons with opposing viewpoints regarding the best treatment, and she has been reading extensively on the Internet and has become confused about her options. Which of the following represents the best treatment for this patient?

A)Modified radical mastectomy, followed by tamoxifen and chemotherapy
B)Chemotherapy with no further treatment to the breast
C)Chemotherapy and tamoxifen, with no further treatment to the breast
D)Chemotherapy and radiation therapy to the breast and axillary regions
E)Chemotherapy, tamoxifen, and radiation therapy to the breast and axillary regions

Question 5

A 32-year-old woman is evaluated because of a painless swelling in her lower neck. She noted the swelling about 3 weeks ago and now thinks it is getting larger. She has no history of foreign travel. She smokes but does not drink alcohol. She owns a cat. She has not had fever or unexplained weight loss, but has had night sweats twice in the past week. She has been feeling fatigued lately and has noted dyspnea on exertion. On physical examination, a 3 X 5-cm left supraclavicular lymph node is palpable. It is firm but not rock-hard and is nontender. The remainder of her physical examination and results of a complete blood count are normal. What is the best next step in this patient"s management?

A)Observe for 2 weeks
B)Refer her to an otolaryngologist for a thorough search for a primary lesion of the oropharyngeal mucosa
C)Administer oral antibiotics and observe the course of the node
D)Perform a needle aspiration of the node
E)Perform a chest radiograph

Question 6

A 63-year-old man is evaluated because of new-onset hemoptysis and a 100-pack-year smoking history. Chest radiograph shows a 4-cm right perihilar mass, and bronchoscopic biopsy and cytologic evaluation of sputum confirm squamous cell carcinoma. There are no significant findings on physical examination, and the patient reports no weight loss.Complete blood count is normal except for a serum alkaline phosphatase level at 110 U/L. CT scans of the chest and abdomen show no mediastinal adenopathy. Results of a positron emission tomography scan are negative, except for the right perihilar mass.In which of the following situations would surgical therapy be offered?

A)A solitary bone metastasis is noted on bone scan, and a lytic lesion is confirmed radiographically.
B)A solitary liver metastasis is noted on CT scan and confirmed by needle biopsy and positron emission tomography scan.
C)A solitary brain metastasis is noted on CT scan of the head.
D)A small effusion is noted in the right hemithorax, and cytopathologic examination of the pleural fluid is positive for tumor.

Question 7

A 40-year-old woman was treated for breast cancer 5 years ago by lumpectomy, breast irradiation, and 3 months of chemotherapy. Her original cancer was negative for estrogen and progesterone receptors and unequivocally positive for HER2. Her periods stopped during chemotherapy but resumed 4 months later, and she remains premenopausal now. She is evaluated now because of pain in her back, a nagging cough, and fatigue. Physical examination shows palpable skin nodules over the affected breast, axillary adenopathy, and dullness to percussion, and decreased breath sounds in the base of the left lung; her liver edge is palpable below the right costochondral border. Liver function values are approximately twice normal; serum bilirubin is normal. Radiograph of the chest shows multiple pulmonary nodules and a left pleural effusion confirmed by CT, which also shows the liver nodules. Bone scan and MRI are consistent with bone metastases. Biopsy of one of the skin lesions is consistent with metast

A)Hospice care and comfort measures
B)Combination endocrine therapy with tamoxifen and an aromatase inhibitor
C)High-dose chemotherapy with bone marrow stem cell support
D)Trastuzumab and taxane-based chemotherapy
E)Combination endocrine therapy with ovarian ablation and an aromatase inhibitor

Question 8

A 65-year-old man has a routine screening examination, and his serum prostate- specific antigen (PSA) level is found to be 6.7 ng/mL. Digital rectal examination reveals a mildly enlarged prostate gland, but no discrete nodules. One year ago, his PSA was 2.1 ng/mL. The patient is referred to a urologist who performs a biopsy of the gland. Biopsy specimen shows adenocarcinoma of the prostate with a Gleason score of 9. Which of the following best describes his prognosis on the basis of his Gleason score?

A)The Gleason score is not reproducible and should not be used as a prognostic variable.
B)Because the patient is asymptomatic, the Gleason score will not be predictive of outcome.
C)The Gleason score indicates that the patient would have a high risk of recurrence after a radical prostatectomy.
D)The Gleason score indicates that the patient would have a very low risk of recurrence after radiation therapy.

Question 9

A 78-year-old man is evaluated because of shortness of breath of acute onset. The patient reports a 13.6-kg (30-Ib) weight loss, vague upper abdominal discomfort, nausea, loss of appetite, and fatigue. He has hypertension and symptomatic atherosclerotic coronary artery disease despite optimal medical management. Even before the recent episode of dyspnea, his physical activity has been limited; he spends most of the day resting either in bed or in a chair.Laboratory studies: Hemoglobin 10.5 g/dL Serum albumin 2.6 g/dLSerum alanine aminotransferase 65 U/LSerum aspartate aminotransferase 78 U/L CA 19-94500 U/LArterial oxygen saturation 85% by pulse oximetrySpiral CT scan of the chest shows a pulmonary embolism.The patient is hospitalized for anticoagulation and oxygen therapy and gradually improves. Subsequent CT of the abdomen shows a 4-cm mass in the tail of the pancreas and numerous low-attenuation lesions in the liver. CT-guided biopsy of the hepatic lesions and the pancreatic m

A)Best supportive care and referral to a hospice
B)Diagnostic CT-guided biopsy under a heparin window" when the patients clinical status improves
C)Neurolytic celiac axis block
D)Palliative chemotherapy
E)Palliative radiation therapy

Question 10

A 76-year-old man was diagnosed with prostate cancer 8 years ago. At that time he had a serum prostate-specific antigen (PSA) level of 12 ng/mL, a Gleason score of 6, and a clinical stage of T2b (organ-confined on digital rectal examination but involving both lobes of the prostate gland). He was treated with external-beam radiation therapy, and his PSA level dropped to a low of 1.4 ng/mL. Four years later, his PSA level began to rise and now is 14.1 ng/mL. A recent bone scan and CT scans revealed no metastatic disease. His urologist has suggested initiating a course of leuprolide. Which of the following is a potential side effect of leuprolide that the patient should be informed about before commencing therapy?

A)Impaired urinary flow
B)Bone thinning
C)Weight loss
D)Increased hair growth

Question 11

A 68-year-old man with a 60-pack-year smoking history is evaluated because of hemoptysis. Radiograph of the chest shows a right hilar mass and mediastinal widening. CT scans of the chest and abdomen confirm the hilar mass and bulky lymphadenopathy in the mediastinum with no other overt metastases. Bronchoscopic biopsy specimen shows small-cell lung cancer. Bone scan and CT scan of the head are negative for tumor. A low serum sodium level and inappropriately high urine osmolality suggest that he has the syndrome of inappropriate antidiuretic hormone secretion. Which of the following is the most appropriate treatment recommendation?

A)Surgery followed by chemotherapy
B)Radiation therapy followed by chemotherapy
C)Chemotherapy alone
D)Radiation therapy and concomitant chemotherapy
E)Chemotherapy followed by radiation therapy

Question 12

A 78-year-old woman with metastatic breast cancer involving the bones and soft tissues who has been taking hormone replacement therapy is evaluated in the emergency department because of lethargy and weakness, nausea, thirst, and dizziness. She is orthostatic and clinically dehydrated. She has a history of congestive heart failure that has been controlled with medications. Laboratory studies: Blood urea nitrogen 42 mg/dL Total serum calcium 11 .4 mg/dL Serum creatinine 1.6 mg/dL Serum albumin 3.0 g/dL What is the most appropriate initial treatment?

A)Slow rehydration with half-normal saline
B)Intravenous administration of a bisphosphonate
C)Vigorous rehydration with normal saline
D)Intravenous administration of furosemide along with saline rehydration
E)Intravenous administration of corticosteroids

Question 13

A 52-year-old woman who is a nonsmoker has a 3-cm right inguinal lymph node.Biopsy specimen shows a poorly differentiated malignancy that is difficult to characterize by light microscopy. The biopsy specimen is negative for leukocyte common antigen, cytokeratin, and estrogen receptors. Which of the following additional tests would best establish the source of this tumor?

A)Bone scan
B)Measurement of serum carcinoembryonic antigen
C)Stain for S-100
D)Measurement of serum CA 19-9

Question 14

A 59-year-old man who is a heavy smoker presents with cough, shortness of breath, and a sensation of head fullness. Physical examination is notable for cervical venous distention and facial edema. A chest radiograph shows a widened superior mediastinum. What is the most appropriate initial intervention for this patient?

A)Initiation of radiation therapy while a diagnostic work-up is pursued
B)CT of the chest and consultation with a pulmonologist and a thoracic surgeon
C)CT of the chest and a venous dye study to rule out thrombosis of the superior vena cava
D)Mediastinoscopy with biopsy
E)Ventilation/perfusion scan

Question 15

A 29-year-old man was diagnosed with stage II (that is, spread from the primary tumor to retroperitoneal lymph nodes) nonseminomatous germ cell tumor 1 year ago. Treatment included orchiectomy and retroperitoneal lymph node dissection. He now presents with an elevated level of ?-human chorionic gonadotropin hormone and multiple pulmonary lesions ranging in size from 0.61 to 3.22 cm. Needle biopsy specimen of the largest lesion reveals a germ cell tumor consistent with the initial diagnosis. He is asymptomatic. What is the best treatment for this patient?

A)Surgical resection of the lung lesions
B)Combination chemotherapy with bleomycin, etoposide, and cisplatin
C)Radiation therapy to the chest
D)Watchful waiting

Question 16

A 64-year-old woman has the following family history: One sister, who was a smoker, had lung cancer at the age of 63 years; another sister had breast cancer at the age of 70 years. Her father had prostate cancer at 82 years of age, and her mother had breast cancer at age 71 years. She has three other sisters, now aged 58, 60, and 65 years who have no history of cancer. She has two daughters and two sons between the ages of 25 and 39 years, who have no history of cancer. Her ancestry is European in general, and she is not of known Ashkenazi Jewish descent. She is concerned that "cancer runs in the family" and would like to have one of those "gene tests" she has read about. What is the best advice to give her and her family?

A)Have blood testing for abnormalities in known germ-line tumor suppressor genes (such as BRCA-1 and BRCA-2).
B)Encourage her children to have genetic counseling and testing for abnormalities in known germ-line tumor suppressor genes.
C)Advise her children to start routine cancer screening tests immediately, including mammography, colonoscopy or sigmoidoscopy, and prostate-specific antigen testing.
D)Advise her that genetic testing is unnecessary, and recommend that she and her family continue screening and risk-reduction strategies as recommended for the general population.
E)Recommend bilateral prophylactic mastectomies and oophorectomies for her and her daughters.

Question 17

A 72-year-old man is evaluated because of back pain and fatigue. Laboratory values indicate he is anemic, with normal leukocyte count and platelet count. He has mild hypercalcemia and a normal serum creatinine level. His gamma globulins are elevated, and serum protein electrophoresis shows the presence of a monoclonal protein, an IgG- K light chain containing immunoglobulin at 4.4 g/dL. His bone marrow contains 20% plasma cells. A skeletal survey reveals multiple osteolytic lesions in the spine, ribs, and skull. Therapy with melphalan and prednisone is initiated. Which of the following agents would NOT be routinely used in his management?

A)Erythropoietin
B)Radiation therapy
C)Intravenous gamma globulin
D)Adequate analgesia (including narcotics, if necessary)
E)A bisphosphonate

Question 18

Which of the following statements is correct about alpha-feto protein (AFP) ?

A)Moderately elevated AFP is almost diagnostic of hepatocellular carcinoma.
B)Hepatitis cannot give rise to raised AFP.
C)Lectin-binding AFP is not a tumor-specific marker.
D)Hook effect can explain the apparently normal level of AFP in hepatoblastoma.
E)AFP should not be raised in germ cell tumor.

Question 19

Which of the following statement about tumor markers is correct?

A)Carcino-embryonic antigen (CEA) is a tumor-specific marker in colorectal cancer.
B)CEA is mainly used for determining prognosis and detecting relapse.
C)Human chorionic gonadotrophin (hCG) cannot be used to screen gestational trophoblastic disease in patients with molar pregnancy.
D)Raised hCG in peri-menopausal and post-menopausal women is always abnormal.
E)Phantom hCG is detected in gestational trophoblastic disease.

Question 20

A 58-year-old man presents with weight loss and haemoptysis. He has smoked most of his life. On examination he is clubbed and has clinical evidence of right pleural effusion. His serum calcium is 3.2mM. Which of the following histological type of lung cancer is he most likely to suffer from?

A)mesothelioma
B)small cell carcinoma
C)large cell carcinoma
D)squamous cell carcinoma
E)adenocarcinoma

Question 21

Which of the following is an oncogene?

A)The N-Myc gene
B)The WT1 (first Wilm's tumor) gene
C)The Retinoblastoma gene
D)The WT2 (second Wilm's tumor) gene
E)The BCRabI translocation (Philadelphia chromosome)

Question 22

Which of the following does not have a role in the management of chronic cancer pain?

A)Carbamazepine
B)Clodrinate
C)Dexamethasone
D)Nifedipine
E)Pinavarium

Question 23

4- A 64-year-old man is found to have squamous cell bronchogenic carcinoma. Which of the following statements is true regarding surgical resection?

A)An FEV1 of 2 L is a major contraindication to surgical resection.
B)Hypercalcaemia makes further assessment for surgery unnecessary.
C)Is precluded if a CT scan of the thorax shows enlarged mediastinal lymph nodes.
D)Positive sputum cytology excludes the need for bronchoscopic examination of the airways
E)The presence of finger clubbing indicates that liver metastases are already present.

Question 24

An elderly lady with breast cancer is starting diamorphine elixir for painful bony metastases. Which of the following is the most appropriate comment to make to her caregiver.

A)Sedation is likely to be an ongoing problem with diamorphine
B)If pain relief is not adequate cocaine may need to be introduced
C)A laxative will need to be used
D)Dependence on diamorphine is likely and could cause problems
E)The same dose could be given IM to achieve the same effect.

Question 25

A 45-year-old woman noticed tinnitus in her left ear which progressed over some weeks to hearing loss in that ear. On physical examination she is found to have a marked decrease in hearing on the left, with Rinne test indicating air conduction better than bone conduction. The other cranial nerves I - VII and IX - XII are intact. A brain MRI scan revealed a solitary, fairly discreet, 3 cm mass located in the region of the left cerebellopontine angle. Which of the following statements is most appropriate to tell the patient regarding these findings?

A)A test for HIV-1 is likely to be positive
B)Other family members should undergo MR imaging of the brain
C)Remissions and exacerbations are likely to occur in coming years
D)The lesion can be resected with a good prognosis
E)You are unlikely to survive for more than a year