Board Preparation: Breast Cancer, CNS Cancers

Aug 31, 2017

Test your knowledge of breast cancer and central nervous system (CNS) 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 40-year-old woman underwent an excisional breast biopsy (lumpectomy) and sentinel lymph node sampling following a core biopsy, which showed invasive breast cancer. The pathology revealed a 2.5-cm invasive ductal cancer that involved one out of four sentinel lymph nodes. The invasive carcinoma was ER-positive, PR-positive, and HER2-negative.

Which of the following will optimize local-regional control of her disease?

  1. A completion axillary lymph node dissection       
  2. A completion mastectomy          
  3. Whole-breast radiation therapy (WBRT)
  4. A bilateral mastectomy

 

2. A 35-year-old woman without prior health problems suddenly experienced the onset of transient headache and dizziness, followed by a generalized tonic-clonic seizure. Emergency department evaluation included a computed tomography (CT) scan of her head that revealed a mass lesion in the right frontal lobe and slight mass effect. Subsequent magnetic resonance imaging (MRI) revealed patchy enhancement. She underwent anterior right frontal lobe resection with gross total resection. Pathology revealed an anaplastic oligodendroglioma characterized by 1p and 19q deletion by fluorescent in situ hybridization (FISH) as well is IDH1 mutation detected by immunohistochemical stains.

Which of the following is the most appropriate treatment now?

  1. Radiation therapy plus procarbazine/CCNU (lomustine)/vincristine (PCV) chemotherapy
  2. Temozolomide alone     
  3. Radiation therapy alone
  4. PCV alone

 

Rationales

1: C

Breast-conserving surgery and WBRT is comparable to mastectomy in terms of OS. The ACOSOG Z0011 trial demonstrated adequate disease control without a need to completely dissect the axilla if one to three sentinel lymph nodes were involved and breast-conserving WBRT was performed. Removal of the uninvolved contralateral breast has not been shown to improve survival.

Suggested Reading:

Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575.

2: A

While temozolomide clearly has antitumor activity in patients with anaplastic oligodendroglioma, the only proven beneficial adjuvant chemotherapy treatment is PCV when added to radiation therapy. In two separate phase III trials, PCV plus radiation was associated with improved survival in patients with 1p and 19q deletions. Radiation alone for this patient population results in inferior outcomes. Neither PCV alone nor temozolomide alone has been established as equivalent to the combination of radiation and PCV for patients with 1p/19q codeletion and IDH mutation. Thus, radiation plus adjuvant PCV is the current standard of care for patients with anaplastic oligodendroglioma with 1p/19q deletions.

A current international phase III trial for patients with anaplastic oligodendroglioma and 1p/19q deletion is investigating other adjuvant options: in this study patients are randomly assigned to radiation therapy plus PCV (control arm), or radiation therapy plus temozolomide, or, in a small cohort of patients, temozolomide alone followed by radiation therapy upon tumor progression. Patients with oligodendrogliomas whose tumors lack 1p/19q deletions or IDH mutations do not appear to derive benefit from adjuvant PCV chemotherapy.

Suggested Reading:

Cairncross G, Wang M, Shaw E, et al. Phase III trial of chemoradiotherapy for anaplastic oligodendroglioma: long-term results of RTOG 9402. J Clin Oncol. 2013;31:337-343.        

van den Bent MJ, Brandes AA, Taphoorn MJ, et al. Adjuvant procarbazine, lomustine, and vincristine chemotherapy in newly diagnosed anaplastic oligodendroglioma: long-term follow-up of EORTC brain tumor group study 26951. J Clin Oncol. 2013;31:344-350.                

Cairncross JG, Wang M, Jenkins RB, et al. Benefit from procarbazine, lomustine, and vincristine in oligodendroglial tumors is associated with mutation of IDH. J Clin Oncol. 2014;32:783-790.

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