Board Preparation: Palliative Care, Central Nervous System Tumors

Dec 14, 2015

Test your knowledge to assist your preparations for Board examinations with questions on palliative care and central nervous system tumors from courses on ASCO University®. Visit university.asco.org for information about available self-assessment courses.

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

Take a comprehensive approach to your Board or Maintenance of Certification preparations with the latest edition of ASCO-SEP®. The fourth edition features more than 180 self-assessment questions and 21 chapters that provide the most current information on all major cancer types, cancer prevention and epidemiology, the molecular biology of cancer, palliative care, symptom management, and geriatric care, as well as overviews of clinical pharmacology, biologic therapies, and statistics. Visit university.asco.org/SEP for more information.

1. A 28-year-old woman with stage IIIB diffuse large cell lymphoma presents for her second cycle of cyclophosphamide/ doxorubicin/vincristine/ prednisone (CHOP) plus rituximab. She complains of 5 days of intractable hiccups after her first cycle of therapy.

The best recommendation for treatment of her hiccups is:

A. Decrease the dose of dexamethasone
B. Baclofen
C. Lansoprazole
D. Gaviscon

2. A 54-year-old woman presents to the emergency department with progressive left-sided weakness over the past 2 weeks. She has a history of HER2-positive breast cancer treated 3 years ago with mastectomy, chemotherapy, and trastuzumab. The results of a whole-body PET scan completed 1 month ago were normal. An MRI demonstrates a solitary ringenhancing 5-cm metastasis in the patient’s right frontal lobe with surrounding vasogenic edema.

Which of the following is the most appropriate treatment option for this patient?

A. Systemic chemotherapy
B. Stereotactic radiosurgery
C. Surgical resection
D. Intrathecal methotrexate
E. Whole-brain radiation therapy

Rationales

1: B

For reasons that are obscure, corticosteroids cause hiccups. In this case, the corticosteroids are required as part of the patient’s lymphoma treatment. Therefore, treatment with a skeletal muscle relaxant like baclofen is the most appropriate choice. The hiccups are not due to excess stomach acid, so lansoprazole will be ineffective. Similarly, the hiccups are not caused by stomach gas, so a surfactant like gaviscon will also be ineffective.

2: C

In general, surgery should be considered for patients with good prognostic factors when there is a single metastasis in an accessible location, especially if the tumor is producing mass effect. This approach is based on the results of two prospective randomized trials. In both studies, reasonably functional patients with a single brain metastasis and well-controlled extracranial disease were randomly assigned to receive needle biopsy of the metastasis followed by whole-brain radiation therapy (WBRT) versus surgical resection followed by WBRT. Patients in the surgery plus WBRT group had fewer local recurrences, improved survival (40 weeks vs. 15 weeks, and 10 months vs. 6 months), and better Karnofsky performance status than patients who received WBRT alone. Studies have been unable to replicate these results in patients with active extracranial disease and lower performance status. Compared with surgery alone, WBRT after surgical resection of a single brain metastasis leads to a marked reduction in recurrence rate (18% vs. 70%) and in the rate of death due to neurologic causes (14% vs. 44%). An overall survival benefit has not, however, been demonstrated .

Suggested Reading

Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med. 1990;322:494-500.

Vecht CJ, Haaxma-Reiche H, Noordijk EM, et al. Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol. 1993;33:583-90.

Patchell RA, Tibbs PA, Regine WF, et al. Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA. 1998;280:1485-9.

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