Board Preparation: Gastrointestinal Cancers, Lymphomas

Jun 27, 2016

Test your knowledge of gastrointestinal cancers and lymphomas to assist your preparations for Board examinations with questions from a past edition of ASCO-SEP®, ASCO’s self-evaluation program in oncology.

The new fifth edition of ASCO-SEP is available for purchase from the ASCO University® bookstore. Featuring 21 updated chapters and more than 180 new self-assessment questions in the book, as well as a 120-question comprehensive mock exam online, this resource is perfect for Board preparation, and can be used to earn Maintenance of Certification and Continuing Medical Education credit. Visit ASCO University for information about the latest edition of ASCO-SEP and other self-assessment resources.

Correct answers, rationales, and suggested reading are listed at the bottom of the page.

1. Your patient, a 35-year-old woman who smokes and has a 15-year history of inflammatory bowel disease, comes for an appointment accompanied by her 45-year-old sister, who has been diagnosed with an advanced intrahepatic cholangiocarcinoma. The patient is very concerned that she might develop the same malignant disease as her older sister and asks you for advice. In your discussions with the patient’s sister, what could be the most important factor predisposing the patient to the development of a cholangiocarcinoma?

A. Her young age
B. Her smoking history
C. Her family history
D. Her history of inflammatory bowel disease
E. She is not at a higher risk for the development of a cholangiocarcinoma compared with the average population
 

2. A 42-year-old man presents with mild shortness of breath, a sensation of chest pressure, and night sweats. A staging work-up with FDGPET/ CT imaging reveals a 7-cm anterior mediastinal mass, retroperitoneal adenopathy, and FDG-avid splenic nodules. The bone marrow is uninvolved. Lab testing reveals a normal complete blood count, differential, and albumin, but a slightly elevated sedimentation rate (45 mm/hour). A biopsy demonstrates classical Hodgkin lymphoma with typical Hodgkin Reed-Sternberg cells. He is treated with six cycles of doxorubicin/bleomycin/vincristine/ dacarbazine (ABVD) and achieves a complete remission.

Two years later, his disease relapses with right cervical adenopathy and intra-abdominal adenopathy. He is treated with three cycles of ifosfamide/carboplatin/etoposide (ICE) and achieves a complete remission documented by FDG-PET/CT at the end of treatment. How would you treat this patient now?

A. No further therapy
B. Administer brentuximab vedotin every 3 weeks for six cycles
C. Consolidate with autologous stem cell transplantation (ASCT)
D. Consolidate with allogeneic stem cell transplantation (alloSCT)

Rationales

1: D

Patients with inflammatory bowel disease are at risk for the development of primary sclerosing cholangitis which  predisposes her to cholangiocarcinomas. These cancers occur most commonly in woman over the age of 50. Smoking has not been established as a risk factor for the development of cholangiocarcinomas and familial syndromes associated with biliary cancers are rare.

Suggested Readings

Shaib Y, El-Serag HB: The epidemiology of cholangiocarcinoma. Semin Liver Dis. 24:115-25, 2004

LaRusso NF, Shneider BL, Black D, et al: Primary sclerosing cholangitis: summary of a workshop. Hepatology. 44:746-64, 2006

Valle J, Wasan H, Palmer DH, et al: Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med. 362:1273-81, 2010

 

2: C

This patient has had a chemotherapy-sensitive relapse of classical Hodgkin lymphoma and now is in a second complete remission. Two randomized trials have demonstrated markedly superior PFS when such patients receive consolidation therapy with high-dose chemotherapy and ASCT compared with patients treated conservatively without transplantation. More recent data suggests that patients who are FDG-PET-negative after ICE or gemcitabine/vinorelbine/liposomal doxorubicin (GVD) chemotherapy and then receive consolidation therapy with ASCT have a long-term PFS as high as 75% to 80%. No study has shown improved outcomes with alloSCT compared to ASCT for HL, and alloSCT is associated with higher transplant-related morbidity and mortality, hence answer D is not a good choice. Brentuximab vedotin is a very exciting new anti-CD30 targeted antibody-drug conjugate that is approved for patients who have disease relapse following ASCT or who are not transplant candidates, but no randomized trials have yet been conducted to suggest it can displace the current standard of care (ASCT) for this population of patients.

Suggested Readings

Schmitz N, Pfistner B, Sextro M, et al. Aggressive conventional chemotherapy compared with high-dose chemotherapy with autologous haemopoietic stem-cell transplantation for relapsed chemosensitive Hodgkin’s disease: a randomised trial. Lancet. 2002;359:2065-2071. PMID: 12086759.

Linch DC, Winfield D, Goldstone AH, et al. Dose intensification with autologous bone-marrow transplantation in relapsed and resistant Hodgkin’s disease: results of a BNLI randomised trial. Lancet. 1993;341:1051-1054. PMID: 8096958.

Moskowitz CH, Matasar MJ, Zelenetz AD, et al. Normalization of pre-ASCT, FDG-PET imaging with second-line, noncross-resistant, chemotherapy programs improves event-free survival in patients with Hodgkin lymphoma. Blood. 2012;119:1665-1670. PMID: 22184409.

Younes A, Gopal AK, Smith SE, et al. Results of a pivotal phase II study of brentuximab vedotin for patients with relapsed or refractory Hodgkin’s lymphoma. J Clin Oncol. 2012;30:2183-2189. PMID: 22454421.

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