Oct 25, 2021
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.
The latest edition of ASCO-SEP includes 22 updated peer-reviewed chapters and 90 self-assessment questions with answer rationales and references, significantly redesigned to maximize learning and refreshed to keep the content current and attuned to your evolving learning needs. This includes timely information, such as recently published guidelines, drug approvals, and updated treated algorithms. Also featured with ASCO-SEP Digital are links to additional ASCO resources, including education courses, podcasts, and recent Virtual Meeting presentations.
Visit ASCO Education to learn more about an annual subscription to our Self-Evaluation products.
Correct answers are listed at the bottom of the page.
Question 1: Breast Cancers
A 71-year-old woman with a history of coronary artery disease and right lower extremity deep vein thrombosis (DVT) underwent an annual mammogram screening. A cluster of microcalcification was seen on the upper outer quadrant of the right breast. The patient underwent a stereotactic core biopsy of the lesion, demonstrating a ductal carcinoma in situ (DCIS), grade 2, cribriform and micropapillary type with focal calcifications. An MRI of the breast showed a fine background enhancement in the right breast and a rim enhancing lesion on the biopsy site. No other abnormal mass or enhancement was seen in the bilateral breast or bilateral axilla. Partial mastectomy results indicated a 15-mm DCIS, grade 2, cribriform type without microinvasion, necrosis, or angiolymphatic invasion. All margins were at least 5 mm from the DCIS. The DCIS was estrogen receptor-negative and progesterone receptor-negative. The patient presents to the medical oncology clinic for consultation.
Which is the most appropriate recommendation regarding systemic therapy?
- Tamoxifen for 5 years
- Anastrozole for 5 years
- Low-dose tamoxifen for 5 years
- No systemic therapy
Question 2: Lung Cancers
A 36-year-old man with a 10-year history of smoking presented with a right upper lung mass. Workup showed a poorly differentiated lung adenocarcinoma. The patient underwent a right upper lobectomy that showed final stage IB (T2a, N0, M0). Molecular testing showed no evidence of EGFR mutation or anaplastic lymphoma kinase translocation. The PDL-1 expression revealed a tumor proportion score of 24%. Family history included multiple primary cancers, including colorectal cancer in his sister at age 32, father at age 46, paternal uncle at age 40, and paternal grandmother at age 41. Based on the Amsterdam criteria, he underwent additional workup and was found to have a germline variant in exon 19 of the MLH1 gene. His resected lung tumor underwent immunohistochemistry (IHC) analysis, which showed positive staining for MLH2 and MSH6, but negative for MLH1 and PMS2. Also, DNA from the lung tumor was positive for microsatellite instability (MSI) in three microsatellite markers, indicating MSI–high tumor. He received adjuvant chemotherapy. He was diagnosed with metastatic disease, including adrenal metastases and single right cerebral hemispheric metastatic disease, and was treated with gamma knife therapy 6 months later. He received systemic palliative chemotherapy with cisplatin, pemetrexed, and bevacizumab. After four systemic palliative chemotherapy cycles, progression with metastases in the L2 and L3 vertebral bodies is noted.
Which of the following is the most appropriate next step?
- Pemetrexed and bevacizumab
- Nivolumab or pembrolizumab
- Docetaxel and ramucirumab
- Carboplatin and gemcitabine
Question 1 Rationale and Reference
Correct Answer: D. No systemic therapy
Rationale: The definite benefit of taking anti-estrogen therapy for chemoprevention in women with estrogen receptor-negative DCIS is unknown and concrete recommendations are lacking. The oncologist should discuss this with the patient. The benefit of anti-estrogen therapy in this case with a history of coronary artery disease and DVT cannot outweigh the therapy's risks; thus, it should not be recommended.
- Allred DC, Anderson SJ, Paik S, et al. Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24. J Clin Oncol. 2012;30:1268-73.
Question 2 Rationale and References
Correct Answer: B. Nivolumab or pembrolizumab
Rationale: The family history of this patient is highly suggestive of Lynch syndrome. This was confirmed by the patient undergoing germline mutation testing. In addition, his lung adenocarcinoma showed IHC stains consistent with the loss of expression of MLH1 and PMS2. Further, DNA from the lung tumor was positive for MSI in 3 microsatellite markers, indicating MSI–high tumor. Although lung adenocarcinoma associated with Lynch syndrome is rare, the practice of doing biomarker analysis on metastatic lung cancer—including testing for PDL 1, MSI, tumor mutational burden, and next-generation sequencing—can guide personalized therapy.
- Masuzawa K, Asakura T, Ikemura S, et al. Long-Lasting Response to Nivolumab for a Patient With Lynch Syndrome-Associated Lung Adenocarcinoma. JCO Precis Oncol. 2020;4:PO.19.00156.
- Marcus L, Lemery SJ, Keegan P, et al. FDA Approval Summary: Pembrolizumab for the Treatment of Microsatellite Instability-High Solid Tumors. Clin Cancer Res. 2019;25:3753-8.