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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?

Which of the following statements applies to glioblastoma?

A 45-year-old woman without any comorbidities, performance status 1, with a KRAS mutated colonic cancer presents with multiple lung, liver and lymph node metastases 2 years after adjuvant chemotherapy with capecitabine and oxaliplatin. Which systemic treatment is recommended?

A 51-year-old, otherwise healthy woman is diagnosed with a T4d invasive ductal adenocarcinoma of the right breast, G3, ER/PR 80%. There is clinical evidence of axillary lymph node involvement. PET/CT shows M0. What is the correct treatment?

A 61-year-old woman, former smoker with 20 pack years, is diagnosed with a T2 N1 M0 lung cancer. EBUS (endoscopic bronchial ultrasound) reveals small cell cytology. You order concomitant chemoradiation and start with chemotherapy immediately. After 2 cycles, before starting radiotherapy, restaging shows stable disease (10% regression). What is the appropriate next step?

A 62-year-old woman presents with 8kg weight loss over 1 year and a persistent cough over 3 months. She has a history of type II diabetes and hypertension, both well controlled. A thoraco-abdominal CT reveals multiple pulmonary nodules, all smaller than 1cm. In addition, there are enlarged retroperitoneal lymph nodes, some lytic vertebral bone lesions and a cervical mass extending to the left pelvic wall. The biopsy of the cervical mass shows poorly differentiated squamous cell cancer. Her performance status is 1 and she wishes the most active treatment. What is the most adequate treatment?

A 30-year-old non-smoking-man in good condition presents with lymph node, lung and liver metastases of TTF-1 and CK7+ adenocarcinoma. Staging procedures, including a PET scan, revealed no primary tumour. Which is the most appropriate next step?

A 70-year-old woman, performance status 1, presents with severe vaginal bleeding because of a stage IVB clear cell endometrial grade III carcinoma with multiple lymph node, peritoneal and lung metastases. Which is the most appropriate treatment in this case?

Peptide receptor radionuclide therapy (PRRT) activity in neuroendocrine tumours is dependent on:

A 86-year-old patient is admitted to the hospital because of an epileptic seizure. The MRI of the brain shows a round mass in the right frontal lobe, with broad contact to the dura mater and some calcifications. There is a considerable perifocal oedema. A CT scan of the chest and abdomen reveals no abnormalities. The patient has a history of prostate cancer 16 years previously, cT1 cN0 M0 treated with radiotherapy with 74 Gy. His current PSA is 3.7 ng/ml. He was recently hospitalized for hematuria: a stage T1a urothelial carcinoma was removed. He also experienced a non-ST elevation myocardial infarction (NSTEMI) 2 months earlier. He takes low-dose aspirin and a beta-blocker.
What is the most likely diagnosis?

A 70-year-old female patient is diagnosed with breast cancer (adenocarcinoma NST). The diagnostic workup reveals a cT3 (multicentric) cN1 M0 tumour with ER 15% positive, PR 2%, HER-2 negative, the Ki67 proliferation marker is 31%. The patient has no concomitant diseases. What is the correct management?

A 50-year-old woman is treated with nivolumab because of metastatic lung cancer. She presented with dyspneoea due to pneumonitis grade II. No pathogen was cultured. Which is the most appropriate approach after stopping nivolumab?

A 52-year-old patient with breast cancer receives the first cycle of an adjuvant (anthracyclin based) chemotherapy, and seven days later experiences a fever of 38.7 °C. Laboratory tests are obtained, and her absolute neutrophil count is 0.3 x 109/L. She has no focal symptoms. The MASCC (multidisciplinary association of supportive care in cancer) score shows high risk. An appropriate strategy could consist of which of the following options?

Which cytostatic drug has a severe interaction with aprepitant?

A 79-year-old frail man presented with a history of diarrhoea, acute diverticulitis and perforation. At laparotomy, an unresectable tumour in the caecum and liver metastases in both lobes were detected. Histology showed a well differentiated neuro-endocrine tumour (NET). The patient recovered from the complications of the diverticulitis. Which is the most appropriate management of the patient with regard to the NET?

A 45-year-old patient with a history of hypertension presented with a large (12cm) gastric mass. A thoraco-abdominal CT scan reveals no other lesions. Biopsy shows a GIST with a high mitotic count. In the multidisciplinary tumour-board surgery is considered feasible but would include removal of the spleen and pancreas in order to obtain an R0 resection. What is the best way to proceed?

Which statement concerning high-grade osteosarcomas is correct?

An 82-year-old patient has metastatic pancreatic cancer with severe abdominal pain, non-responsive to paracetamol. His liver function is normal, the creatinine-clearance is 28ml/min. What is the best pain management?

A patient with metastatic castration resistant prostate cancer and newly diagnosed bone metastasis starts treatment with abiraterone acetate and denosumab. Eight weeks later he presents with dizziness and muscle cramps. The most likely diagnosis is:

Which is the standard duration of adjuvant trastuzumab therapy in HER2- positive early breast cancer patients?

A 55-year-old woman in good clinical condition presents with two liver metastases of about 2cm in size. Further examination does not reveal other lesions. She had a history of ER positive, PR positive and HER2 negative breast cancer and had been treated with adjuvant chemotherapy (anthracycline, taxane), radiotherapy and adjuvant endocrine therapy with tamoxifen until 2 years ago. How would you proceed with this patient?

Regarding metastatic breast cancer, for which of the following patients, current evidence supports the use of platinum-based chemotherapy in second line?

A 60-year-old lady was started on bortezomib for multiple myeloma. One month after treatment start she presented with a rash (see picture ). 

What is the appropriate management?

A 37-year-old man underwent a palliative right-sided hemicolectomy because of a stenotic colon ascendens carcinoma with extensive peritoneal metastases. Histology revealed adenocarcinoma of the colon G3, biomarker analysis showed KRAS and NRAS wildtype and a BRAF V600E mutation. According to tumour board decision a palliative systemic treatment is recommended for this patient without relevant comorbidities. Which is the most effective first line protocol in terms of overall survival?

What is true of a traditional phase I trial?

In a 65-year old male patient with a PS 1 a bronchial adenocarcinoma of the right upper lobe is found. The tumour measures 3.5 cm. PET-CT reveals metastases in the suprarenal glands, several vertebrae and 2 lesions in the liver. The patient is a heavy smoker (60 pack years) and drinks 0.5 litre of red wine/day. He is known to have gout and mild cutaneous psoriasis. The PD-L1 expression in the tumour cells is 55%, no EGFR, ALK or ROS-1 mutations are found. Which treatment will result in the best overall survival?

What is the standard first-line chemotherapy regimen for a patient with metastatic cholangiocarcinoma?

Which is the target of Ipilimumab?

A 45-year-old woman presented with retroperitoneal and mediastinal lymphadenopathy. Histologically squamous cell carcinoma was diagnosed. No primary tumour was found by CT and MR scanning, endoscopy, bronchoscopy, ENT-endoscopy and gynaecologic examination. Further tissue examination revealed positivity for human papilloma virus. Which is the most probable diagnosis?

A 64-year-old man in good performance status and otherwise healthy state presents with macrohematuria. An abdominal ultrasound reveals a 10cm mass in the right kidney. Additional CT staging shows multiple 1cm lung metastases. The next step should be:

Which of the following statements with regard to primary brain tumours is appropriate?

Which is the most common epithelial ovarian cancer subtype?

A patient with adenocarcinoma of the lung with a known EGFR exon 19 mutation has been treated with an EGFR TKI for 12 months. Staging CT shows progression of the primary and new liver metastases. Which is the most likely cause of progression in this patient?

A 75-year-old man presents with splenomegaly, enlarged lymph nodes in axillae, and the para-aortic region. Blood counts: Hb 6 mmol/l (10 g/l), platelets 95 x 109/l, leucocytes 24 x 109/l with 69% monoclonal lymphocytes, CD20+, CD5+, CD23-, Ig-M+, Ig-D+. Lymph node biopsy: monoclonal lymphocytes, Cyclin D1+. What is the most likely diagnosis?

A fit 20-year-old man has a primitive neuro-ectodermal tumour (PNET, Ewing tumour group) of the chest wall without metastases. Which treatment should the patient receive?

Which cancer's incidence is NOT elevated in BRCA-1/2 mutation carriers?

Metastatic melanoma harbouring a BRAFV600-mutation can be treated with a combination of BRAF- and MEK- inhibitors. Which statement concerning this combination therapy in comparison to BRAF-inhibitors monotherapy is NOT true?

The international workshop on chronic lymphocytic leukaemia defined criteria for 'active disease', identifying patients for whom therapy is indicated. Which parameter is NOT an indication for treatment?

Which statement about peripheral neuropathy (PN) secondary to chemotherapy is NOT true?

A 58-year-old man was diagnosed with a metastatic gastro-oesophageal junction cancer (adenocarcinoma G3, HER2 negative). He received a platinum - fluoropyrimidine doublet chemotherapy as first-line treatment. Tumour progression was observed after 4 cycles. Which one is NOT an appropriate monotherapy option?

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

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