Board Preparation: Head and Neck Cancers, GI Cancers

Jul 14, 2017

Test your knowledge of head and neck cancers and gastrointestinal cancers with questions from a past edition of ASCO-SEP®, ASCO’s self-evaluation program in oncology.

The fifth edition of ASCO-SEP is available for purchase in 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 university.asco.org 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. A 56-year-old male non-smoker presents with a complaint of “neck swelling” for a duration of 2 months. He denies pain, fever, chills, sore throat, or dental issues. He received several courses of antibiotics without relief. Flexible pharyngolaryngoscopy did not demonstrate any lesions. Exam demonstrates a 3 cm firm, right level 2 neck mass. The mass is not tender to palpation. Fine needle aspiration of the mass demonstrates squamous cell carcinoma.

What is the most appropriate next step in order to define a primary site of disease?

A. Serologic evaluation for EBV (Epstein-Barr virus)
B. HHV-8 testing of tumor sample
C. p16 IHC of tumor sample
D. Serologic evaluation of HIV

 

2. A 34-year-old male presents with a chief complaint of double vision of approximately 1-week duration. On exam, he is found to have a VI nerve palsy on the left. He is also noted to have a 2 cm left level IV cervical lymph node. Flexible laryngopharyngoscopy demonstrates a mass in the nasopharynx. Biopsy of the mass demonstrates squamous cell carcinoma and the tumor is positive for EBV gene expression. PET/CT scan demonstrates a mass in the nasopharynx with extension to base of skull and bilateral involved cervical lymph nodes.

What is the most appropriate next step?

A. Surgery followed by radiation therapy
B. Surgery followed by cisplatin based concurrent chemoradiotherapy
C. Radiation therapy alone
D. Sequential chemotherapy and chemoradiotherapy
 

3. A 64-year-old patient with a 20-year history of hepatitis C and mild cirrhosis (Child-Pugh A) who is being monitored with yearly alpha-fetoprotein AFP levels and abdominal magnetic resonance imaging (MRI) shows an increase in AFP levels from 18 ng/dL to 200 ng/mL. .The MRI identifies a new 4-cm lesion in the periphery of the right liver lobe with imaging characteristics supportive of a hepatocellular carcinoma (HCC). No other new focal abnormalities can be found in the liver.

What is the best next step in the management of the patient’s situation?

A. Ultrasound guided biopsy of the suspicious intrahepatic lesion
B. PET/CT scan to rule out distant metastases
C. Transarterial chemoembolization (TACE) of the liver followed by surgical resection of the liver lesion
D. Radiofrequency ablation of the liver lesion
E. Surgical resection of the liver lesion

 

4. A 46-year-old female presents with mild abdominal fullness and reflux symptoms. Physical exam was negative. Lab testing was unremarkable. EGD showed a sub-serosal gastric mass. Biopsy showed sheets of spindle cells, invasive, and CD117+ (cKIT) on immuno-histochemistry staining. A partial gastrectomy is performed and the tumor measures 6 cm and has more than 10 mitoses per HPF, 0 of 7 nodes positive. She recovers well from the surgery. Staging work up including a PET scan is negative for metastasis.

Which of the following should you recommend?

A. 36 months of imatinib 400mg a day
B. 4 cycles of ifosfamide and doxorubicin
C. Post-operative radiation therapy
D. 12 months of imatinib 400 mg a day
E. 6 months of imatinib 400 mg a day

 

5. A previously healthy 50-year-old woman presents with nausea, right upper quadrant pain, and weight loss. Physical examination reveals hepatomegaly. ECOG performance status is 1. Upper endoscopy reveals a mass in the gastric cardia with a biopsy showing well-differentiated adenocarcinoma. A CT scan of the abdomen and pelvis reveals bilateral ovarian masses and bilateral multilobar hepatic metastases. Liver functions and complete blood count are within normal limits.

What is the most appropriate approach in this situation?

A. Supportive care
B. Single-agent chemotherapy
C. Combination chemotherapy
D. Radiation therapy to the tumor bed

 

Rationales

1: C

This case represents a head and neck carcinoma of unknown primary (CUP). Immunohistochemistry (IHC) for p16 is a well-recognized marker for the presence of the Human Papillomavirus (HPV). The presence of HPV(p16) positive neck metastasis correlates significantly with an initially occult primary cancer in the oropharynx. In one study, approximately 74% of head and neck CUP was positive for p16.

While serologic testing for EBV might aid in the diagnosis or prognosis of a nasopharyngeal carcinoma, the clinical scenario points to an HPV-related malignancy and should not be the first diagnostic consideration.

Serologic evaluation of HIV and HHV-8 testing of tumor samples do not have a routine role in the work up of head and neck carcinoma of unknown primary.

 

Suggested Readings

Keller LM, Galloway TJ, Holdbrook T, et.al. P16 status, pathologic and clinical characteristics, biomolecular signature and long-term outcomes in head and neck squamous cell carcinomas of unknown primary. Head Neck. 2014 Dec;36(12):1677-84.

Vent J, Haidle B, Wedemeyer I, et.al. p16 expression in carcinoma of unknown primary: diagnostic indicator and prognostic marker. Head Neck. 2013 Nov;35(11):1521-6.

 

2: D

A large meta-analysis of eight trials with individual patient data for 1753 patients demonstrated a pooled hazard ration of death of 0.82 (95 % confidence interval, 0.71-0.94, p=0.006) corresponding to an absolute survival advantage of 6% at 5 years with the addition of chemotherapy to RT alone. It is unclear at this time whether induction chemotherapy or adjuvant chemotherapy adds significant clinical benefit to chemoradiotherapy alone. However, sequential chemotherapy (either induction or adjuvant) with chemoradiotherapy remains the standard of care. Surgery does not have a role in the treatment of newly diagnosed nasopharyngeal carcinoma.

 

Suggested Reading

Baujat B, Audry H, Bourhis J, et.al. Chemotherapy in locally advanced nasopharyngeal carcinoma: an individual patient data meta-analysis of eight randomized trials and 1753 patients. Int J Radiat Oncol Biol Phys. 2006; 64 (1): 47-56.

 

3: E

The patient's medical background (hepatitis C), the increase in AFP level, and the radiographic criteria of sequential MRI studies confirm the presence of a hepatocellular carcinoma (HCC), no biopsy is needed here. The sensitivity of PET imaging in HCCs is low and thus PET is not recommended in the staging of patients with HCC. TACE is useful as palliative therapy for unresectable, liver-limited HCC with adequate liver function, but not an appropriate approach for a resectable solitary HCC lesion. The risk of local recurrence after radiofrequency ablation is high for lesions over 3 cm in diameter and should only be considered if surgical resection is impossible. The best approach for this patient is upfront resection of the liver lesion. The STORM trial failed to show a survival benefit with sorafenib following resection or ablation for HCC.

 

Suggested Readings

Bruix J, Takayama T, Mazzaferro V, et al. Adjuvant sorafenib for hepatocellular carcinoma after resection or ablation (STORM): a phase 3, randomised, double-blind, placebo-controlled trial. Lancet. 16(13):1344-54.

Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet. 362:1907-17, 2003.

Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 359:378-90, 2008.

Germani G, Pleguezuelo M, Gurusamy K, et al. Clinical outcomes of radiofrequency ablation, percutaneous alcohol and acetic acid injection for hepatocelullar carcinoma: a meta-analysis. J Hepatol. 52:380-8, 2010.

Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. Hepatology. 37:429-42, 2003.

 

4: A

Adjuvant therapy for at least 36 months is recommended for GIST patients with high-risk tumors (tumor size > 5cm, > 5 mitosis per 50 HPF, tumor rupture or risk of recurrence > 50%). A randomized phase III trial showed treatment with imatinib for 36 months compared to 12 months in patients with high-risk GIST led to an improvement in overall survival and relapse-free survival.

 

Suggested Readings

Joensuu H, Eriksson M, Hall KS, et al. Adjuvant Imatinib for High-Risk GI Stromal Tumor: Analysis of a Randomized Trial. J Clin Oncol. 2016;34(3):244-50.

Dematteo RP, Ballman KV, Antonescu CR, et al. Adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumour: a randomised, double-blind, placebo-controlled trial. American College of Surgeons Oncology Group (ACOSOG) Intergroup Adjuvant GIST Study Team. Lancet. 2009 Mar 28;373(9669):1097-104.

 

5: C

Although incurable with chemotherapy, patients with metastatic gastric cancer have improved survival with chemotherapy compared to best supportive care. In general, combination chemotherapy results in higher response rates and improved progression free and overall survival compared to single agent chemotherapy, and in a good performance status patient with normal organ function combination chemotherapy is preferred. Primary radiation therapy is suboptimal here as the patient has disseminated metastatic disease and initial systemic therapy for palliation is the most appropriate initial therapeutic approach.

There is no clear consensus about what represents standard first-line chemotherapy. Per the TOGA trial, patients with HER2–positive disease derive survival benefit from the addition of herceptin to 5FU/platinum based treatment. There is conflicting data regarding role of triplets versus doublets. Doublets are in general preferred due to better tolerance. CALGB80403 was a randomized phase II study that showed no survival difference between ECF vs. FOLFOX. Triplets can be considered in very fit patients willing to deal with significant toxicities. In a randomized phase III study, docetaxel, cisplatin, and 5-FU achieved superior response, progression free and overall survival compared to 5-FU and cisplatin alone. Toxicity of this regimen was substantial and therefore cannot be recommended across the board.

 

Suggested Readings

Van Cutsem E, Moiseyenko VM, Tjulandin S et al. Phase III study of docetaxel and cisplatin plus fluorouracil compared with cisplatin and fluorouracil as first-line therapy for advanced gastric cancer: a report of the V325 study group. J Clin Oncol 24: 4991-7; 2006.

Bang Y-J, Van Cutsem E, Feyereislova A, et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Lancet. 376(9742):687-97.

Al Batran SE, Hartmann JT, Probst S et al. Phase III trial in metastatic gastroesophageal adenocarcinoma with fluorouracil, leucovorin plus either oxaliplatin or cisplatin: a study of the Arbeitsgemeinschaft Internistiche Onkologie. J Clin Oncol. 2008 Mar 20;26(9):1435-42.

Enzinger PC, Burtness BA, Niedzwiecki D, et al. CALGB 80403 (Alliance)/E1206: A Randomized Phase II Study of Three Chemotherapy Regimens Plus Cetuximab in Metastatic Esophageal and Gastroesophageal Junction Cancers. J Clin Oncol. 2016;34(23):2736-42.

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