Dec 07, 2021
Test your knowledge of head, neck, and thyroid cancers, as well as sarcoma and skin cancers, with two multiple-choice questions from ASCO Education.
ASCO seeks to advance the education of all oncology professionals and ultimately facilitate and support enhanced patient care. The ASCO Oncology Self-Assessment Series on ASCO Connection consists of free case-based multiple-choice practice questions, educational links, and answer rationales. Questions are developed by a group of oncology experts in multiple tumor topic areas. The self-assessment questions are aligned with the American Board of Internal Medicine (ABIM)’s Medical Oncology blueprints and ASCO’s Medical Oncology In-Training Exam (ITE) blueprints.
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Correct answers are listed at the bottom of the page.
Question 1: Head, Neck, and Thyroid Cancers
A 60-year-old woman presents with an enlarging right parotid mass that developed over 2 months. She reports no medical comorbidities and takes no medications. She has no additional symptoms, and her neurologic examination is unremarkable. Laboratory studies, including renal and liver function studies, are unremarkable. MRI and contrast-enhanced CT of the head and neck show a 2.5-cm enhancing mass in the right parotid gland with no lymphadenopathy. Chest CT shows no evidence of metastatic lesions. The mass is resected, confirming a 2.5-cm adenoid cystic carcinoma with positive perineural invasion, but no named nerve involvement and negative surgical margins.
Based on this patient's characteristics, what is the most appropriate treatment plan?
- Observation
- Adjuvant cisplatin (100 mg/m2) IV for three cycles
- Adjuvant concurrent radiation therapy and cisplatin
- Adjuvant radiation alone
Question 2: Sarcoma and Skin Cancers
A 65-year-old man with a metastatic gastrointestinal stromal tumor (GIST) is referred to you by his local oncologist. The patient had metastatic disease to the liver on diagnosis and was treated with imatinib 400 mg daily for the last 5 months. He has tolerated imatinib well overall, with the only adverse effects of intermittent diarrhea and fatigue. His local oncologist obtained new imaging, which is evident for progressive disease in the liver. You obtained mutational testing of the tumor, which showed a D842V mutation in exon 18 of PDGFRA.
Which of the following is the most appropriate next step?
- Escalate imatinib dose
- Change therapy to sunitinib
- Change therapy to avapritinib
- Change therapy to regorafenib
Question 1 Rationale and References
Correct answer: D. Adjuvant radiation alone
Rationale: Adenoid cystic carcinoma in this setting has a relatively high rate of local recurrence, which is why observation would not be appropriate in this case. When it comes to options B and C, the utility of cytotoxic chemotherapy in managing adenoid cystic carcinoma is undefined. National Comprehensive Cancer Network guidelines recommend adjuvant radiation therapy for resected T2 adenoid cystic carcinoma.
References
- Lee A, Givi B, Osborn VW, et al. Patterns of care and survival of adjuvant radiation for major salivary adenoid cystic carcinoma. Laryngoscope. 2017;127:2057-62. DOI: http://doi.org/10.1002/lary.26516.
- Safdieh J, Givi B, Osborn V, et al. Impact of adjuvant radiotherapy for malignant salivary gland tumors. Otolaryngol Head Neck Surg. 2017;157:988-94. DOI: http://doi.org/10.1177/0194599817717661.
- Tanvetyanon T, Fisher K, Caudell J, et al. Adjuvant chemoradiotherapy versus with radiotherapy alone for locally advanced salivary gland carcinoma among older patients. Head Neck. 2016;38:863-70. DOI: http://doi.org/10.1002/hed.24172.
- Amini A, Waxweiler TV, Brower JV, et al. Association of adjuvant chemoradiotherapy vs radiotherapy alone with survival in patients with resected major salivary gland carcinoma: data from the National Cancer Data Base. JAMA Otolaryngol Head Neck Surg. 2016;142:1100-10. DOI: http://doi.org/10.1001/jamaoto.2016.2168.
Question 2 Rationale and Reference
Correct answer: C. Change therapy to avapritinib
Rationale: Avapritinib is the only tyrosine kinase inhibitor approved for GIST harboring PDGFRA exon 18 mutations, including D842V, based on the NAVIGATOR trial. This open-label phase I study included 56 patients with GIST. For patients with the D842V mutation, an overall response rate of 88% was observed with 9% experiencing complete responses, 79% experiencing partial responses, and 13% with stable disease. The 12-month duration of response was 70%. Common adverse effects of avapritinib include edema, nausea, fatigue, cognitive impairment, vomiting, anorexia, and diarrhea.
Reference
- Heinrich MC, Jones RL, von Mehren M, et al. Avapritinib in advanced PDGFRA D842V-mutant gastrointestinal stromal tumour (NAVIGATOR): a multicentre, open-label, phase 1 trial. Lancet Oncol. 2020;21:935-46. DOI: http://doi.org/10.1016/S1470-2045(20)30269-2.