Sep 10, 2018
Test your knowledge of sarcoma and lymphoma with questions from self-evaluation activities on ASCO University.
For additional self-evaluation and study, the sixth edition of ASCO-SEP is now available for purchase in the ASCO University® bookstore (university.asco.org/SEP). The new edition features 22 new and updated chapters and more than 190 brand new self-assessment questions in the book, as well as an online mock exam with 120 original self-assessment questions. Upon successful completion of both the ASCO-SEP book self-assessment questions and the mock exam, participants may request Continuing Education, American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC), Nursing, and Pharmacy credit through online modules. Visit university.asco.org for information about the latest edition of ASCO-SEP and other self-assessment resources.
Correct answers are listed at the bottom of the page. Find complete answer rationales and suggested reading at ASCOconnection.org/TEC, as well as additional questions to test your knowledge.
- A 29-year-old man is status post resection of a high-grade osteosarcoma of the distal femur and presents to discuss future treatment. Several months ago, he presented to an orthopedist with severe left knee pain that he attributed to increased exercise. Workup revealed a high-grade osteosarcoma of the distal femur; he then received 4 cycles of neoadjuvant doxorubicin and cisplatin and then underwent limb salvage therapy. His preoperative bloodwork was notable for white blood cell count (WBC) 3.4 x 10^9 cells/L, hemoglobin (Hb) 8.4 g/dL, platelets 127/uL, creatinine 1.3 mg/dL, alkaline phosphatase 286 U/L. Pathology revealed a 4.3-cm, grade 2, conventional osteosarcoma with 67% necrosis and negative margins.
What finding will most negatively impact this patient's survival?
- Degree of necrosis
- Distal femur location
- Alkaline phosphatase
- Histologic subtype
- A 28-year-old woman presents to the ER with shortness of breath and chest pain. She also reports drenching night sweats for the past two weeks. On exam, her temperature is 38.3°C, blood pressure is 115/70 mmHg, heart rate is 115 beats/min, and O2 saturation is 98% on room air. She appears uncomfortable and she has mild lymphadenopathy of the left cervical chain, but no hepatosplenomegaly. Her labs show a hemoglobin of 10 g/dL, total leukocyte count of 3.0x10^9/L with an absolute lymphocyte count of 500 and platelet count of 187 x 10^9/L. Her erythrocyte sedimentation rate is 110. A chest X-Ray is done which shows a widened mediastinum. A follow up CT chest/abdomen/pelvis shows a 7-cm mediastinal mass and left cervical lymphadenopathy. A biopsy of the mediastinum is done and reveals classical Hodgkin lymphoma. The patient is otherwise healthy.
At what intervals should PET and CT scans be done for this patient?
- PET after cycle 4 and at the end of treatment. CT scan as clinically indicated.
- PET after cycle 4 and at the end of treatment. CT scan every 6 months for the first 2 years.
- PET after cycle 2, 4 and at the end of treatment. CT scan every 3-4 months for the first 2 years.
- PET at the end of treatment. CT scan every 3-4 months for the first 2 years.
- PET at the end of treatment. CT scan as clinically indicated.
Less than 90% necrosis to neoadjuvant chemotherapy has been found to significantly impact survival from osteosarcoma. Extremity location is favorable. Preoperative hemoglobin has not been shown to play a role. Pretreatment alkaline phosphatase has prognostic value but no clear value in pre-operative alkaline phosphatase.
Risk adapted treatment is becoming more common in Hodgkin lymphoma. For stage I/II disease, PET scans are typically done after cycle 4 of treatment and the Deauville score determines what further treatment a patient should receive. In stage III/IV disease, PET scans are done after cycle 2 of treatment. The follow up imaging criteria were recently modified (Lugano 2014) to decrease the number of post treatment CT scans. Previously, CT scans were done on a regular basis. However, this did not demonstrate any difference in outcomes or improved detection of relapse. If an end of treatment PET scan confirms complete remission, no further CT scans are needed unless clinically indicated. It is reasonable to get one CT scan within the first 12 months of finishing treatment but not after. PET scans are overly sensitive and may give false positive results and should not be used after treatment has ended.