FRANZCR Examination Phase 2 Radiation Oncology

Transcription

1 FRANZCR Examination Phase 2 Radiation Oncology Pathology February 2015 Time Allowed: 3 Hours INSTRUCTIONS ALL QUESTIONS are to be attempted. There are a total of SIX (6) questions. All questions are of equal value. The marks allocated to each sub-part of the questions are indicated in brackets. Hand all papers to the invigilator. No papers are allowed to be taken from the examination room. THIS INCLUDES THE QUESTION PAPERS. Pathology February 2015 Page 1 of 3

2 Question 1 a. In an adult patient presenting with a painless testicular mass: i List the malignant tumours of the testis. Discuss the role of a fine needle aspiration and core biopsy in establishing a testicular tumour diagnosis. b. Describe the: i clinical presentation and patterns of spread, (8) i iv macroscopic and microscopic features, immunohistochemistry and prognostic factors for spermatocytic seminoma and diffuse large B cell lymphoma of the testis. Question 2 a. Regarding radiation injury to the brain, describe: i the acute, subacute and late clinical manifestations. the pathophysiology of the acute, subacute and late effects. b. List the factors that increase the risk of developing radiation injury to the brain. Question 3 A biopsy of a polypoid lesion of the right colon confirms adenocarcinoma. The patient elects to undergo a right hemicolectomy. a. List the risk factors for the development of adenocarcinoma of the colon. b. List the macroscopic and microscopic features that should be included in the synoptic pathology report of the hemicolectomy specimen. c. What are the prognostic and therapeutic implications of the presence of: i microsatellite instability KRAS mutation d. Define Lynch Syndrome, and write short notes on the pathological and epidemiological factors associated with it. Pathology February 2015 Page 2 of 3

3 Question 4 a. Regarding primary vulva cancers, list: i the associated risk factors for squamous cell carcinoma. the other non-squamous histological types. (1) b. Describe the pathological criteria used in the FIGO staging system for vulva cancer. Sentinel lymph node biopsy (SLNB) is widely used in the surgical management of cancer. c. Describe the general principles of SLNB and how it is performed. d. Discuss the specific advantages and disadvantages of SLNB when used in the management of vulva cancer. Question 5 a. Define paraneoplastic syndrome. How are these syndromes mediated? b. Write brief notes on the following para-neoplastic syndromes. Include in your answer for each, the causal mechanisms and the commonly associated malignancies. i Hypercalcaemia (8) i iv Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) Myasthenia syndrome Carcinoid syndrome Question 6 a. Discuss the factors to consider when selecting a method for obtaining a histological diagnosis of a mass suspected of being a soft tissue sarcoma. What biopsy method is usually recommended? b. Write brief notes on the epidemiology, microscopy, immunohistochemistry and cytogenetics of the following sub-types of soft tissue sarcoma. i extraosseous Ewing s sarcoma/pnet, (6) i liposarcoma and synovial sarcoma c. Describe the patterns of spread of soft tissue sarcoma. Pathology February 2015 Page 3 of 3

4 FRANZCR Examination Phase 2 Radiation Oncology Clinical Oncology February 2015 Time Allowed: 3 Hours INSTRUCTIONS ALL QUESTIONS are to be attempted. There are a total of SIX (6) questions. All questions are of equal value. The marks allocated to each sub-part of the questions are indicated in brackets. Hand all papers to the invigilator. No papers are allowed to be taken from the examination room. THIS INCLUDES THE QUESTION PAPERS. Clinical Oncology February 2015 Page 1 of 4

5 Question 1 A fit 71 year old woman presents with worsening inter-scapular pain. X-rays confirm a T4 vertebral body compression/pathological fracture and a further lytic lesion in the T11 vertebral body. Preliminary investigations demonstrate a haemoglobin of 98g/L, and a total protein of 80g/L. a. What further investigations would you require to establish a diagnosis? Justify your answers. A MRI of the whole spine confirms extensive replacement of T4 with an associated paravertebral mass extending from T2-5. There is no spinal cord compression. Further lytic lesions are seen throughout the whole vertebral column. Bone marrow examination confirms plasma cells > 30%. The serum protein electrophoresis demonstrates a pathologically elevated monoclonal IgG peak. Urinary Bence-Jones protein is positive. Renal function is normal b. i Outline your initial management plan for this patient and her subsequent treatment options. What additional supportive measures would you need to consider in the management of this patient? c. In general, in newly diagnosed multiple myeloma, what would you discuss with the patient regarding their diagnosis, likely response to treatment and survival? Question 2 A 60 year old woman presents with a 3cm mass in the left supraclavicular fossa. FNA shows poorly differentiated carcinoma. a. How would you further evaluate this patient? Justify your answer? A core biopsy confirms adenocarcinoma. Staging investigations fail to demonstrate a primary tumour. b. In general, what are the unfavourable prognostic factors for patients with adenocarcinoma of unknown primary? c. What is the role of peripheral blood tumour markers in this patient and what tumour markers would you request. Justify your answer. d. Investigations reveal multiple liver and lung metastases. What possible chemotherapy agents would you recommend for this patient? Justify your answer. Clinical Oncology February 2015 Page 2 of 4

6 Question 3 Anticancer treatments may impair fertility in cancer patients. a. What are the mechanisms by which anticancer treatments may impair fertility? b. Describe techniques and potential success rates of fertility preservation strategies in the following patients: i i A prepubertal girl who is to commence fertility impairing cytotoxic chemotherapy. A 30 year old woman requiring 36 Gy in 18 fractions of radiation treatment to the left pelvic and groin nodes for a low grade lymphoma. A 35 year old male requiring a pelvic and para-aortic radiation field following an orchidectomy for a seminoma. Question 4 Epigenetic modification of MGMT (O6 methylguanine-dna methyltransferase) DNA repair has been shown to influence outcome of treatment for Glioblastoma multiforme (GBM). a. What are the other prognostic factors known to impact on the outcome for GBM? Justify your answer. b. Discuss the mechanism of MGMT promoter methylation and its prognostic significance. Justify your answer. c. If a reliable assay for this promoter methylation was available in Australasia, how would this influence your clinical practice? d. Discuss the role of i Temozolomide and Bevacizumab in the systemic therapy of GBM. What are the main toxicities of these agents? Clinical Oncology February 2015 Page 3 of 4

7 Question 5 a. Define Health Related Quality of Life (HRQoL). b. Why is it important to measure HRQoL in clinical trials? c. For a HRQoL measurement tool to be effective what characteristics must it have? d. If you were conducting a research trial with a HRQoL component, what factors would you need to consider in the choice and use of the measurement tool? Question 6 With regard to depression in cancer: a. Discuss the prevalence of depression in cancer patients and the factors which may predispose a patient with cancer to experience depression. b. Discuss the possible manifestations of depression in cancer patients. c. What would your approach be to the treatment of depression in cancer patients? Clinical Oncology February 2015 Page 4 of 4

8 FRANZCR Examination Phase 2 Radiation Oncology Radiation Therapy 1 February 2015 Time Allowed: 2.5 Hours INSTRUCTIONS ALL QUESTIONS are to be attempted. There are a total of FIVE (5) questions. All questions are of equal value. The marks allocated to each sub-part of the questions are indicated in brackets. Hand all papers to the invigilator. No papers are allowed to be taken from the examination room. THIS INCLUDES THE QUESTION PAPERS. Radiation Therapy 1 February 2015 Page 1 of 4

9 Question 1 A 42 year old man, previously treated with chemotherapy for Acute Myeloid Leukaemia, is referred following relapse for total body irradiation (TBI) prior to a bone marrow transplant. a. What would you explain to the patient about the rationale for total body irradiation and the possible acute side effects that he may experience? b. Describe a suitable radiation therapy technique and dose fractionation schedule for TBI. Justify your answer. (5) c. How would you verify the delivery of the prescribed dose? Question 2 A fit 28 year old woman, currently breast feeding a 6 week old baby, develops a rapidly enlarging tender erythematous left breast. Clinical examination demonstrates a large ill defined mass within the breast associated with generalised erythema, skin oedema and palpable axillary lymphadenopathy. Radiological investigations show a 8 cm mass within the breast. Biopsy confirms a Grade 3 infiltrating ducal carcinoma, ER negative, PR negative and Her2 positive. No metastases are demonstrated on further staging. a. What overall management plan would you recommend for this patient? The patient eventually undergoes mastectomy and axillary clearance. Histopathology demonstrates a 3 cm residual malignant mass within the breast with 15 of 18 axillary lymph nodes involved by malignancy. b. Describe a suitable radiation therapy technique and dose fractionation schedule for this woman s treatment. Justify your answer. c. In general: i Outline the potential cardiac side effects of irradiation of the left breast and the estimated frequency with which these occur. Outline what can be done during the planning and treatment process to minimise these side effects? Radiation Therapy 1 February 2015 Page 2 of 4

10 Question 3 A 57 year old HIV positive man, managed on combined antiretroviral therapy, presents with a solitary Kaposi Sarcoma lesion on the hard palate. The lesion is painful and covers the anterior 2/3 rds of the mucosal surface of the hard palate. A decision is made to treat with radiation therapy. a. Describe a suitable radiation therapy technique and dose fractionation schedule. b. What is the expected local control rate? (1) The patient develops a significant symptomatic acute oral mucositis midway through treatment. c. Describe how you would manage this acute reaction and how you would counsel the patient on the expected duration of symptoms. An elderly male presents with classical Kaposi Sarcoma, extensively involving the dorsal surface of the foot and extending around onto the ventral surface (sole) of the foot. A decision is made to treat the whole foot with radiation therapy. d. Describe a suitable radiation therapy technique and dose fractionation schedule. Question 4 A fit 63 year old man with new onset cough presents with an x-ray from his GP. It shows a 3cm central left lung mass with hilar lymph nodes. Sputum cytology confirms small cell carcinoma. Further investigations show the patient has limited stage disease. a. Discuss the role of thoracic radiation therapy in this patient including its rationale, timing, and evidence for use. b. Describe a suitable radiation therapy technique and dose fractionation schedule for the radical treatment of limited stage disease. Justify your answer. c. How would a pleural effusion change your approach to the use of radiation therapy in this patient? Justify your answer. d. In general, what is the role of prophylactic cranial irradiation in Small Cell Lung Cancer? Include in your discussion its rationale, dose and timing. Justify your answer. Radiation Therapy 1 February 2015 Page 3 of 4

11 Question 5 A 59 year old woman presented with a 3cm base of tongue squamous cell carcinoma (HP16 ve) and three left level 3 nodes measuring 2 cm in diameter (T2N2b). She was treated with definitive chemoradiation, receiving 70Gy to gross disease and 54 Gy to the uninvolved neck with 3 cycles of cisplatin 100mglm 2 every 21 days. Two years after this initial treatment she is found to have a 2cm mass in the base of tongue in the previously irradiated area. Fine needle biopsy aspiration confirms squamous cell carcinoma. a. How would you evaluate this patient and justify your answer? Further staging investigations also reveal a 2 cm level 3 node on the right side. There is no evidence of disease elsewhere. b. What are the treatment options for this patient and briefly outline the advantages and disadvantages of each approach? c. The decision is made to reirradiate this patient. Describe a suitable radiation therapy technique and dose fractionation schedule. Justify your answer. d. What is the expected outcome of the treatment? What would be the incidence of late toxicity in this patient? Radiation Therapy 1 February 2015 Page 4 of 4

12 FRANZCR Examination Phase 2 Radiation Oncology Radiation Therapy 2 February 2015 Time Allowed: 2.5 Hours INSTRUCTIONS ALL QUESTIONS are to be attempted. There are a total of FIVE (5) questions. All questions are of equal value. The marks allocated to each sub-part of the questions are indicated in brackets. Hand all papers to the invigilator. No papers are allowed to be taken from the examination room. THIS INCLUDES THE QUESTION PAPERS. Radiation Therapy 1 February 2015 Page 1 of 4

13 Question 1 A 36 year old woman presents with PR bleeding and a 4cm mass in the anal canal. a. Discuss how you would evaluate this patient including relevant history findings. Give reasons for your answers. The patient is fit with no significant comorbidities. A PET-CT scan shows uptake in a 2.5cm right inguinal node and a 2.5cm right external iliac node. The decision is made to treat with concurrent chemoradiation therapy. b. Describe a suitable radiation therapy technique and dose fractionation schedule, including a suitable chemotherapy regimen. c. The patient has anal oedema and a palpable nodule in the anus 8 weeks after the completion of treatment. How would you evaluate and manage this patient? Question 2 A fit 69 year old male presented to his family doctor with new onset cough, hoarseness and odynophagia. On examination he was found to have a 3 cm mass in the left lobe of the thyroid gland. a. What would your initial assessments of this patient be? A biopsy reveals anaplastic thyroid cancer. b. What further assessments would you request for this patient? The patient has no evidence of distant metastatic disease. He undergoes a total thyroidectomy and neck dissection, with preservation of the contralateral recurrent laryngeal nerve. Pathology indicates involvement of the level IV nodes bilaterally and a positive tracheal margin. A decision is made to give radical postoperative radiation therapy. c. Describe a suitable radiation therapy technique and dose fractionation schedule for this patient. d. What would you explain to the patient regarding: (1) i the likelihood of local control with radiation therapy, and the long term survival for patients with anaplastic thyroid carcinoma? e. In contrast to anaplastic carcinomas, papillary and follicular thyroid cancer patients are often treated with I-131. i What are the contraindications to the use of I-131, and its potential toxicities? Radiation Therapy 1 February 2015 Page 2 of 4

14 Question 3 a. A 58 year old woman presents with acute renal failure and vaginal bleeding. On examination she is found to have a locally advanced cervical cancer. Describe your initial management. The patient is stabilised and her renal function is restored. At EUA she is found to have a locally advanced cervical cancer extending to the pelvic side wall. Biopsy confirms squamous cell carcinoma. There is no evidence of metastatic disease. b. Describe a suitable chemoradiation therapy technique and dose fractionation schedule for this patient. c. What would you advise the patient regarding the potential late toxicities, their incidence and management? (5) Question 4 A 72 year old man undergoes a robot assisted radical prostatectomy. His preoperative PSA level was 14ng/ml. The histopathology shows a Gleason of 3+4, with extracapsular extension (T3a) and focally positive radial margins. The sampled lymph nodes are negative. The post operative PSA is undetectable. The patient is referred to you for consideration of adjuvant radiation therapy. a. Discuss the evidence for post-operative radiation therapy in this clinical setting? b. What are the advantages and disadvantages of adjuvant versus salvage radiation therapy for this patient? The patient decides to proceed with adjuvant radiation therapy. c. Describe a suitable radiation therapy technique and dose fractionation schedule for this patient. 2 years after receiving adjuvant radiation therapy treatment the patient s PSA has risen to 10 ng/ml. Restaging shows no radiological evidence of disease. d. What is the role of hormone therapy in this patient? Radiation Therapy 1 February 2015 Page 3 of 4

15 Question 5 A 39 year old woman presents with a 3 month history of worsening focal seizures affecting the left arm on a background of progressive personality change and word finding difficulties. An MRI scan demonstrates an infiltrating lesion in the left frontal lobe with no associated mass effect on T2-weighted sequences. The lesion is nonenhancing on T1-gadolinium sequences. She undergoes maximal surgical resection of the lesion. Histology demonstrates diffuse low grade astrocytoma (fibrillary subtype). a. What are the potential management options for this patient now? What are the advantages and disadvantages of these options? b. What factors need to be considered when deciding upon the best management strategy for this patient? c. A decision is made to treat with radiation therapy. Describe your radiation therapy technique and dose fractionation schedule. Outline the side effects resulting from this treatment that you would discuss with the patient. Eight years after completing therapy, the patient is diagnosed with recurrent disease. She undergoes surgical debulking, with histopathology confirming transformation to a high grade glioma. She progresses on temozolomide. d. In general what factors do you need to take into account when considering offering further radiation therapy? Radiation Therapy 1 February 2015 Page 4 of 4