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ESMO examination trial questions

Type A - Single choice

Select one answer for each question:

- in positively formulated questions select the only correct answer i.e the most appropriate.
- for negatively formulated questions select the only exception, the only incorrect answer that is the answer that appears least appropriate. (The negation is written in bold.)

A 45-year-old patient, who has been treated for metastatic BRAF-wildtype melanoma for 6 weeks, presents in the emergency department with severe fatigue, elevated temperature (37.9 °C) and abdominal discomfort. On examination he has a performance status ECOG 2, oxygen saturation of 96 %, blood pressure 105/70 mmHg, heart rate 102/min and a normal examination of chest and abdomen. Lab values show sodium 132 mmol/L (normal 135-145), potassium 4.6 mmol/L (normal 3.6-4.8), creatinine 67 μmol/l (0.8 mg/dl; < upper limit of normal),
CRP 26 mg/L (normal 0-10).

Which diagnostic step will most likely reveal the underlying problem?

While you are on emergency duty, a 57-year-old patient, who started treatment for metastatic colorectal cancer three weeks ago, presents with an itching rash (see picture). As recommended, he used daily moisturizing cream and protected the skin from the sun. However, he forgot to take the daily pills that your colleague prescribed.

Which „pills“is he most likely referring to?

A 34-year-old woman, desiring future fertility, presents with newly diagnosed breast cancer (cT3 N+ M0, ER-positive, PR- positive, HER2-negative). She’s scheduled to be treated with neoadjuvant anthracycline- and taxane-based chemotherapy, breast surgery, adjuvant radiotherapy and endocrine therapy.

What is important regarding fertility?

Regarding the metabolism of the 5-fluorouracil, which statement is correct?

You see a new patient with metastatic cancer of unknown primary origin. Immunohistochemical work-up shows a CK7- and CK 20-negative tumour.

Which of the following is the most probable origin?

An 82-year-old woman with metastatic HER2-positive, hormone receptor-negative breast cancer suffers from dyspnoea on exertion from pulmonary metastases. Concomitant diseases are well-controlled diabetes mellitus and arterial hypertension. Cardiac, renal and hepatic function are normal for her age. ECOG performance status is 1.

Which is the best management for this patient?

An 82-year-old patient with metastatic castration-resistant prostate cancer has progressive disease upon first-line treatment with enzalutamide. CT scan reveals new bone metastases, multiple enlarged lymph nodes and suspicion of a liver metastasis. He has ischemic heart disease (with a left ventricular ejection fraction of 35 %), diabetes type II with a chronic diabetic foot ulcer, chronic renal insufficiency (glomerular filtration rate of 40 ml/min), and minor cognitive impairment. He needs to rest most of the day.

Which of the following treatment strategies is most appropriate?

A 62-year-old patient with metastatic renal cell carcinoma was treated with third-line cabozantinib for 6 weeks and presented to the emergency department with confusion, polydipsia and constipation. He uses oxycodone 30 mg twice daily for painful bone metastases.

Blood pressure was 102/73 mmHg, heart rate 96/min, temperature 36.5˚ Celsius. Blood analyses show a haemoglobin of 89 g/L (normal 120-160), leucocytes 23 x109/L (normal 3.5-10), creatinine 126 µmol/L (normal 50-105), GFR 51 ml/min,
C-reactive protein 112 mg/L (normal <10), albumin 27 g/L (normal 35-50) and
calcium 3.10 mmol/L (normal 2.28-2.65).

Which of the following options is the most likely diagnosis and proposed treatment?

In patients with metastatic cancer, what is correct about pain management?

A 56-year-old man with metastatic urothelial carcinoma shows tumour progression under first-line chemotherapy with platinum/gemcitabine.

Which of the following drugs improves survival in second-line treatment?

An 82-year-old, otherwise healthy and very fit patient had an amputation of the 5th finger of the left hand because of a melanoma 2 years ago. Histology showed pT3 pN0 (0/1) sn, Breslow 3.3 mm, BRAF wildtype. Now he is diagnosed with symptomatic brain metastases; and asymptomatic soft tissue and lung metastases. He experiences resolution of the neurological symptoms with
4 mg dexamethasone/day.

Which treatment is recommended?

Which of the following criteria is required for a complete remission (CR) according to the International Myeloma Working Group (IMWG) in multiple myeloma?

A 70-year-old man was diagnosed with a lung cancer of 8 cm diameter and infiltration of the right N. laryngeus recurrens. PET-CT showed multiple enlarged hypermetabolic bilateral mediastinal lymph nodes but no distant metastasis. Histological and immunohistological evaluation revealed adenocarcinoma with
PD-L1 expression of 55 % in the tumour tissue. The patient has a good performance status (ECOG 1) and normal renal function.

Which is the optimal approach for this patient?

A 75-year-old man with a 30-year smoking history is diagnosed with metastatic adenocarcinoma of the lung. Performance status is ECOG 1.
Molecular analysis reveals no driver mutation or translocation in EGFR, ALK, ROS-1 and BRAF genes. PD-L1 expression is 80 %.

Which is the most appropriate treatment?

Which mutated gene is associated with HNPCC (hereditary non-polyposis colon cancer)-syndrome?

You are going to manage a 42-year-old man who underwent R0 resection for early stage pancreatic ductal adenocarcinoma. He is otherwise healthy with ECOG performance status 1 and good organ functions.

What is the most appropriate adjuvant treatment?

Which statement regarding Temozolomide is correct?

A 63-year-old woman is diagnosed with a high-grade, serous adenocarcinoma of the ovary, FIGO stage IIIC. She received optimal debulking and recovered well from surgery. She has no concomitant diseases. ECOG performance status is 1. She is a known carrier of a BRCA-1 mutation.

What is the best management for this patient to prevent progression?

A 60-year-old man was diagnosed with a tumour in the rectum (5.5 cm in diameter), 2 mm from the anal sphincter. Biopsy revealed a mesenchymal tumour, spindle cell type, DOG1 and CD117 positive. Staging with PET/CT showed no evidence of metastatic lesions but a high FDG uptake of the rectal mass.

What is the most appropriate treatment strategy?

A 67-year-old woman has symptomatic progression of her metastatic liposarcoma after treatment with doxorubicin.

What is the preferred second-line treatment?

A 57-year-old patient was diagnosed with a cT3 N0, ER positive (25 %), PR negative (0 %), HER2-positive breast cancer. Staging evaluation showed 6 bone metastases, confirmed by histopathologic examination. The patient is asymptomatic.

For which first-line treatment improved overall survival was demonstrated?

A 68-year-old man is newly diagnosed with a prostate cancer showing the following features: Cancer in 6 of 12 core biopsies, bilaterally, Gleason score 4+5=9,
PSA 10.4 ng/dl, CT and bone scan without evidence of lymphadenopathy or distal metastases.

What is the most appropriate treatment plan?

Based on randomised controlled trials, which adjuvant therapy is recommended for a healthy patient with completely resected stage III, BRAF mutant (V600E) malignant melanoma?

A 59-year-old woman presents with dizziness, disorientation, imbalance and large cervical and axillary lymphnodes up to 7 cm. Laboratory analyses show abnormalities in leucocytes 34 x109/L (normal 3.5-10), haemoglobin 91 g/L (normal 120-160), platelets 66 x109/L (normal 150-450), total protein 112 g/L (normal 64-83) and
IgM-concentration 64.5 g/L.

The neurological symptoms are most likely due to:

A 43-year-old patient is newly diagnosed with HIV infection. In addition, a stage IIA diffuse large B-cell lymphoma (DLBCL) is diagnosed.

What is correct?

A patient is treated with FOLFOXIRI plus bevacizumab for metastatic BRAF-mutated adenocarcinoma of the colon. After the second course the patient loses all his hair within 4 days.

Which drug is most likely the cause?

A 65-year-old patient with jaundice is diagnosed with adenocarcinoma of the pancreas. CT scan shows no distant metastases.

Infiltration of which structure is most critical in limiting resectability?

A 60-year-old man presented with a left renal mass. Renal biopsy showed clear cell carcinoma. A CT scan revealed lung and bone metastases. Blood test were normal, except for a haemoglobin of 97 g/L (normal 120-160).

What is the best approach for this patient?

Which of the following factors most prominently increases the fracture risk in postmenopausal women with breast cancer?

A 53-year-old patient with metastatic clear cell renal cell carcinoma is treated with nivolumab after prior progression on sunitinib. He comes for his fourth 2-weekly infusion and complains of diarrhoea for the past few days with 8 liquid stools in the last 24 hours. His blood pressure is 95/60 mmHg, heart rate 103/min and temperature 36.8 ˚C. The patient is admitted for i.v. infusion. Stool examination rule out infection and a colonoscopy is planned.

Besides withholding nivolumab treatment, which of the following treatments should be initiated?

A 67-year-old man with metastatic low-grade small bowel neuroendocrine tumour and carcinoid syndrome receives treatment with octreotide LAR 30 mg every 4 weeks. CT scan and radionuclide examination demonstrate progression of liver and retroperitoneal metastases.

Which of the following treatments has been shown to significantly improve progression-free survival in such patients?

A premenopausal 45-year-old woman underwent breast-sparing surgery with sentinel lymph node biopsy. A grade 1 invasive ductal carcinoma of 7 mm diameter and negative sentinel lymph nodes were found, ER positive/PR positive, HER2-negative.

Which of the following approaches is most appropriate?

Which of the following therapies has the best outcome in a 45-year-old patient with chronic HCV liver cirrhosis, Child-Pugh class A, and hepatocellular carcinoma (one nodule of 2 cm in each lobe; T2 N0 M0)?

What statement is correct about soft-tissue sarcoma (STS)?

A 65-year-old heavy smoker was diagnosed with a pathological vertebral fracture. He complains about shortness of breath when tying his shoes, swollen neck and frequent headaches. A fine-needle aspiration of a supraclavicular lymph node reveals small cell cancer cytology.
What is the next procedure?

A 53-year-old, otherwise healthy patient was diagnosed with a rectal cancer, 15 cm above the anal verge. CT and MRI staging showed T3 N1 M0, negative circumferential resection margin (CRM).
What is the correct treatment strategy?

A 51-year-old otherwise healthy woman presents with a pelvic mass. Surgical staging and optimal debulking reveals a 2 cm epithelial serous ovarian tumour of low malignant potential in the right ovary, with capsule rupture and multiple peritoneal implants without evidence of invasion.
What is the adequate management?

Which result in a randomized trial proves that a cancer screening test "saves lives"?

A biomarker is a measurement variable that is associated with disease outcome.

The following graphs show a biomarker that is:

Which of the following targeted therapies represents standard of care for patients with metastatic or locally advanced basal cell carcinoma that is not amenable to treatment with surgery or radiation therapy?

A 38-years-old patient is diagnosed with metastatic, neuroendocrine tumour (NET) of the lung. Ki-67 is 2%. All lesions show avid uptake in somatostatin receptor-based diagnostic imaging. No neuroendocrine symptoms are present.

What is the most appropriate first-line treatment?

A 42-year-old man in a very good performance status (PS ECOG 0), noticed a large soft tissue mass (20 cm diameter) on his right thigh. Histology revealed a high-grade pleomorphic sarcoma. The multidisciplinary team judged the tumour as marginally resectable.

What is the most appropriate treatment strategy?

A 69-year-old man is diagnosed with an adenocarcinoma of the right colon with multiple liver metastases (RAS wildtype, BRAF mutated [V600E], microsatellite-stable [MSS]). Imaging during first-line treatment with FOLFOXIRI plus bevacizumab shows disease progression.

What is the most appropriate second-line treatment?

Which of the following criteria is recommended to assess treatment response in brain tumours?

Fatigue is a frequent complaint of cancer patients, ranging from tiredness to exhaustion.

Which of the following approaches is recommended by the ESMO guidelines?

The standard treatment for locally advanced anal cancer is chemoradiotherapy (CRT).

What is true concerning this curative approach?

A 74-year-old man presents to his family doctor with progressive dysphagia and weight loss (-4kg in the past 6 weeks). He drinks one bottle of wine every day and has a smoking history of 40 pack-years. Medical history: Coronary artery disease with a stent placement 1 year ago and chronic obstructive pulmonary disease. Diagnostic tests (upper endoscopy with biopsies, endoscopic ultrasound and PET-CT) reveal a squamous cell carcinoma in the mid oesophagus, cT3 cN1 M0.

Which is the most appropriate treatment strategy for this patient?

What is the treatment of choice for patients with locally advanced cutaneous squamous cell carcinoma not amenable to local treatment?

A 64-year-old patient with metastatic bladder cancer has been treated with 6 cycles of cisplatin plus gemcitabine with a partial remission. Performance status is good (ECOG 1) with normal organ functions.

What is the most appropriate next step?

A 68-year-old woman with metastatic breast cancer (ER/PR positive, HER2 negative) has been treated with letrozole and palbociclib as first-line treatment. Now, she experiences disease progression with multiple bone metastases and 4 liver metastases up to 2 cm in diameter. Her performance status is good (ECOG 1), organ functions are normal. Genomic analyses of tumour tissue reveal a PIK3CA mutation.

What is the most appropriate second-line treatment?

A 72-year-old man was newly diagnosed with metastatic prostate cancer and staged as cT3b cN1 cM1 (at least 5 bone metastases: 3 vertebrae, left femur and ribs; 3 lung metastases). Gleason score is 9 (4+5), PSA 378 ng/ml. The patient has no symptoms from the primary tumour.

Which answer is NOT correct?

Which first-line treatment for advanced hepatocellular carcinoma (HCC) has shown the longest progression-free (PFS) and overall survival (OS) in clinical trials?

A 42-year-old patient was diagnosed with a malignant melanoma on his back (superficial spreading melanoma, Breslow thickness of 1.2 mm, no ulceration). Sentinel node biopsy (left axilla) was negative.

Based on current guidelines, which management is appropriate?

A 45-year-old patient with metastatic melanoma is treated with 3-weekly pembrolizumab. Serum analyses after 6 cycles are shown here:

TSH: 0.043 mIU/l (normal 0.500 – 4.20)
fT4: 30 pmol/l (normal 10-25)
basal cortisol: 0.48 µmol/l (normal 0.15 - 0.70)

The patient has no symptoms. Blood pressure is 130/70 mmHg, heart rate 80/min.

What is the diagnosis and the most appropriate management?

Which of the following drugs is associated with the highest risk for infertility in male patients?

After complete resection of the primary tumour and of a single liver metastasis in a patient with metastatic colon cancer, stage pT3 pN1 pM1, you receive the pathology report.

Which of the following results is associated with the worst prognosis?

Report

Localization of primary

KRAS

NRAS

BRAF

MSI

A)

right colon

mut

wt

wt

high

B)

right colon

wt

wt

mut

low

C)

left colon

mut

wt

wt

low

D)

transverse colon

wt

mut

wt

low

E)

distal colon (Sigma)

mut

wt

wt

hig

wt: wildtype; mut: mutated, MSI: microsatellite-instability (by immunohistochemistry)

A 32-year-old woman is diagnosed with stage IVB Burkitt lymphoma. Lymphoma affects supra-clavicular, mediastinal (bulk) and inguinal lymph nodes and the liver (diffuse infiltration).
The patient has a long-term partner, with whom she plans to have children. The extension of the disease requires immediate start of highly gonadotoxic treatment (within the next 10 days).

According to the ESMO guidelines, which is the best strategy for fertility preservation?

A 60-year-old patient has undergone complete resection of an adenocarcinoma of the head of the pancreas. He recovered well from surgery. His only other condition is a longstanding diabetes with grade 3 polyneuropathy. Renal function is normal.

According to the ESMO guidelines, what is the most appropriate further management?

A 72-year-old man with extensive disease small-cell lung cancer (SCLC) is treated with cisplatin plus etoposide. His ECOG performance status is 1. During the first cycle a severe anaphylactic reaction to etoposide occurs.

Which of the following is the best option to replace etoposide in a platinum-based doublet?

Which of the following targeted agents used in advanced breast cancer treatment is associated with an increased risk of venous thromboembolism (VTE)?

A 69-year-old man is newly diagnosed with metastatic, EGFR-mutated non-small-cell lung cancer with PDL-1 expression of 60%.

What is the most appropriate first-line treatment?

The Follicular Lymphoma International Prognostic Index (FLIPI) allows a prognostic differentiation in 3 risk categories concerning the risk of relapse.

Which is NOT a risk factors in this score?

A 79-year-old man is diagnosed with diffuse large B-cell lymphoma (DLBCL), Ann Arbor stage IIIA. Comorbidities are diabetes mellitus, arterial hypertension. He suffered a stroke 5 years ago without persisting neurological deficit. Left ventricular ejection fraction is 55%, creatinine clearance is 55 ml/min. A geriatric assessment shows the following:

Co-medication

4 different drugs/day

Weight

- 2kg over past 6 months

Appetite

decreased

Mental health

good, stable

Cognitive function tests

normal

Social network

strong support by family (lives nearby)

Mobility

independent (daily shopping by foot)

Which is the most appropriate therapy?

A 75-year-old man presented to his family doctor due to progressive fatigue. The laboratory analyses reveal a lymphocytosis of 100 x109/L (normal 1.0-4.8), haemoglobin of 85 g/L (normal 120-160) and platelets of 60 x109/L (normal 150-450). Further studies confirm the diagnosis of a chronic lymphatic leukaemia (CLL).

Which of the following factors is associated with a very good clinical outcome?

A 30-year-old previously healthy woman presents with shortness of breath and chest pain. She also reports night sweats for the past three weeks. On physical exam, she has mild lymphadenopathy of the left cervical chain, no hepatosplenomegaly.

Her labs were normal. A CT scan reveals a 7 cm mediastinal mass and left cervical lymphadenopathy. A biopsy of the mediastinum was performed and shows classical Hodgkin lymphoma. Availability of PET and CT at the treating centre are no issue.

According to the PET-guided approach of the ESMO guidelines, at what intervals should PET and CT scans be done for this patient?

A 64-year-old man with a locally advanced laryngeal carcinoma underwent total laryngectomy. Due to extracapsular spread he received adjuvant chemoradiation. He completed his therapy 10 months ago. In the follow-up consultation he complains about severe fatigue, forgetfulness and dry skin. He has a dry mouth, but he can eat solid food.

Which of the following is the most appropriate next step?

A 67-year-old patient with newly diagnosed chronic lymphocytic leukaemia (CLL) with a deletion del(17p) and several comorbidities needs a first-line treatment.

What is the most appropriate treatment?

A 55-year-old man with newly diagnosed non-small-cell lung cancer (NSCLC) of the left upper lobe reports constant sweating of the left forehead.

Which lesion explains this patient‘s symptom?

Which of the following are the best validated prognostic factors for GIST?

A 54-year-old woman presents with chest pain and shortness of breath. CT scan showed multiple pleural and lung metastases. A biopsy of an enlarged axillary lymph node was performed and showed an ER negative, PR negative, HER2 positive breast cancer.

Which is the most appropriate first-line therapy?

A 75-year-old man was referred because of an elevated PSA serum level (16 ng/ml). He has no specific complaints.

Which is the most appropriate first diagnostic procedure?

Which of the following statements about adrenocortical carcinoma (ACC) is FALSE?

Which is NOT a typical side effect of bleomycin?

A 64-years-old patient with metastatic ER positive, PR positive, HER2 negative breast cancer is treated with fulvestrant and a CDK4/6-inhibitor. After 8 months of stable disease, re-staging shows progression with 5 new liver metastases and unchanged bone metastases. ECOG performance status is 1. Laboratory values are normal except for mildly increased serum levels of ASAT and ALAT (1.8xULN).

What is the most appropriate next step?

A patient with small and fragile veins needs to start systemic treatment in the outpatient setting. Peripheral vein access for iv-infusion is difficult, but usually possible after two or three attempts. The patient is reluctant to obtain a central venous access.

For planned repeated administration of which of the following drugs is a central venous access strongly recommended despite the patient’s reluctance?

Many orally administered drugs should not be taken together with grapefruit juice.

Which pharmacokinetic process is mainly affected by this interaction?

Adjuvant chemotherapy should be offered to fully staged patients with early stage ovarian cancer (stage I–IIA), EXCEPT:

Which of the following is the most reliable indicator of pain?

Regarding Hodgkin lymphoma, what is correct?

Which of the following skin toxicities is NOT typically observed during single-agent treatment with an anti-EGFR monoclonal antibody?

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