Oncology Self-Study: Breast and Gastrointestinal Cancers

Apr 18, 2018

Test your knowledge of breast and gastrointestinal cancers with questions from one of ASCO’s self-assessment resources, ASCO University Essentials.

ASCO University Essentials has several self-assessment activities to test your medical oncology knowledge. For a more in-depth look at questions and their rationales or to test your knowledge on the go, the ASCO University Podcast series has self-evaluation episodes where experts discuss questions sourced from existing ASCO University activities. The ASCO University Podcasts deliver weekly episodes on topics including recent oncology drug approvals and ASCO Guidelines in addition to the self-assessment discussions. Complete access to the series is available exclusively to ASCO University Essentials subscribers and to those enrolled in ASCO's Education Essentials for Oncology Fellows (EEOF).

Correct answers are listed at the bottom of the page.

1. A 55-year-old woman presents with a 4-cm right breast mass and palpable right axillary lymph nodes.  A needle biopsy of the breast mass and a lymph node are both positive for infiltrating ductal carcinoma, negative for hormone receptors and negative for HER2/neu expression.  The patient is interested in breast conservation therapy and she is referred to you for consideration of neoadjuvant chemotherapy.

Which of the following do you tell her?

  1. Patients having a complete response to neoadjuvant chemotherapy have lower local/regional recurrence rates.
  2. Mastectomy will be required, regardless of clinical response to chemotherapy.
  3. Chemotherapy will be administered before and after surgery.
  4. Randomized trials have shown that radiotherapy is not necessary following surgery and chemotherapy if she has a complete response.

2. A 67-year-old woman with a history of hypertension and chronic hepatitis C goes to her primary care physician for her annual physical examination. She overall feels well and denies any acute complaints. On routine bloodwork, she was found to have an elevation in her alkaline phosphatase that led to an abdominal ultrasound revealing an indeterminate liver lesion. She was then sent for a triple-phase CT of the abdomen/pelvis with contrast that revealed a 6-cm lesion in the right lobe of the liver with two satellite nodules measuring 1.5 cm in greatest dimension in the same segment that was consistent with hepatocellular carcinoma. A CT scan of the chest did not reveal any lung lesions.

What is the next appropriate step in the treatment of this patient?

  1. Sorafenib
  2. Transarterial chemoembolization and sorafenib
  3. Surgical resection
  4. Surgical resection followed by adjuvant sorafenib
  5. Liver transplantation

Rationale

1: A

Studies have shown that chemotherapy before surgery (neoadjuvant) versus chemotherapy after surgery (adjuvant) is associated with similar outcomes.  In a patient who is not an upfront surgery candidate, neoadjuvant chemotherapy increases the probability of breast conserving surgery.  Pathologic complete response in the breast and lymph nodes is associated with lower local/regional recurrence rates.  NSABP/RTOG phase III trial is ongoing to evaluate regional radiotherapy in women presenting with clinical N1 axillary node disease before neoadjuvant chemotherapy and become pathologically node-negative at the time of surgery.

Suggested Readings

NCT01872975.  Standard or Comprehensive Radiation Therapy in Treating Patients with Early-Stage Breast Cancer Previously Treated with Chemotherapy and Surgery. https://clinicaltrials.gov/ct2/show/NCT01872975

Esserman LJ, Berry DA, DeMichele A, et al.  Pathologic complete response predicts recurrence-free survival more effectively by cancer subset: Results for I-SPY 1 TRIAL-CALGB 15007/150012. ACRIN 6657.  J Clin Oncol 2012; 30:332442-3249.               

Cortazar P, Zhang L, Untch M, et al.  Pathologic complete response and long-term benefit in breast cancer:  the CTNeoBC pooled analysis.  Lancet Oncol. Epub 2014, Feb 14.

2: C

Potentially curative partial hepatectomy is the optimal treatment for hepatocellular carcinoma in patients with adequate liver functional reserve. The ideal patient for resection has no radiographic evidence of invasion of the hepatic vasculature, no evidence of portal hypertension, and well-preserved hepatic function. Long-term relapse-free survival rates average 40% or better, and 5-year survival rates as high as 90% are reported in carefully selected patients.

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 Oncol. 2015;16:1344-1354.

Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53:1020-1022.

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