Mar 11, 2022
Test your knowledge of genitourinary cancer and lung cancer with two multiple-choice questions from the ASCO Self-Evaluation Program (ASCO-SEP) on 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.
Review the Education Essentials for Oncology Fellows (EEOF) package, which includes the ASCO Self-Evaluation Program (ASCO-SEP), hosted on ASCO Education for more online education.
Correct answers are listed at the bottom of the page.
Question 1: Genitourinary Cancer
Five months ago, a 32-year-old man presented with right testicular swelling. Work-up revealed a complex right testicular mass. Lactate dehydrogenase (LDH) and alpha-fetoprotein (AFP) levels were normal; however, human chorionic gonadotropin (hCG) level was 83 mIU/mL. Pathology findings from a right-sided radical orchiectomy were consistent with pure seminoma. Postoperative laboratory results included normal LDH and AFP levels, and hCG level of 3 mIU/mL. A CT scan of the chest, abdomen, and pelvis was notable for a 6-cm right retroperitoneal mass and a 1.2-cm left lower lobe lung nodule. He is now recovering well from three cycles of bleomycin, etoposide, and platinum chemotherapy and presents for his first posttreatment visit. LDH, AFP, and hCG levels are within normal limits. A CT of the chest, abdomen, and pelvis revealed resolution of the lung nodules and a decreased retroperitoneal mass, 2.8-cm in size, without other evidence of metastatic disease.
Which of the following is the most appropriate next step?
- Order a PET/CT scan
- Start salvage chemotherapy
- Initiate routine surveillance
- Retroperitoneal lymph node dissection (RPLND)
Question 2: Lung Cancer
A 75-year-old man who is a former smoker (15 pack-years), with a history of working in the shipyard for 35 years before retirement, presents to his primary care physician with dyspnea on exertion that has worsened in the past two months. Chest radiographs showed a large left-sided pleural effusion. Pleural effusion recurred quickly after thoracentesis. A follow-up contrast-enhanced CT of the chest showed large left pleural effusion, left-side pleural nodularity, left-side paratracheal and subcarinal lymphadenopathy, along with a right-side hilar node, which measured 2.2 x 2.0 cm. A video-assisted thoracic biopsy of left parietal and visceral revealed sarcomatoid pleural mesothelioma. A PET/CT did not show right-side involvement or extrathoracic metastasis. He was healthy up until now, with only mild hypertension, and has an Eastern Cooperative Oncology Group performance score of 1.
After placing a port, which of the following is the most appropriate next step?
- Carboplatin and pemetrexed, with or without bevacizumab
- Pemetrexed with bevacizumab
- Pembrolizumab
- Nivolumab and ipilimumab
Question 1 Rationale and References
Correct answer: C. Initiate routine surveillance
Rationale: Patients with advanced seminoma, who have normal tumor markers and a residual mass smaller than 3 cm after systemic chemotherapy, should initiate surveillance without other evidence of metastatic disease. There is a high likelihood of ongoing regression of the mass. A PET/CT may help determine the presence or absence of viable tumors in a residual mass larger than 3 cm. Salvage chemotherapy is reserved for those with clear evidence of progressive or relapsed disease. Salvage radiation is not indicated after primary chemotherapy in men with advanced seminoma. For a patient with nonseminoma, the most appropriate strategy would be RPLND.
References
- Cathomas R, Klingbiel D, Bernard B, et al. Questioning the value of fluorodeoxyglucose positron emission tomography for residual lesions after chemotherapy for metastatic seminoma: results of an international global germ cell cancer group registry [published online ahead of print, 2018 Oct 4]. J Clin Oncol. 2018;JCO1800210. DOI: https://doi.org/10.1200/JCO.18.00210.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Testicular Cancer, Version 1.2021. https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf
Question 2: Rationale and References
Correct answer: D. Nivolumab and ipilimumab
Rationale: Malignant pleural mesothelioma occurs in patients with exposure to asbestos. The whole course is often indolent and pleural effusion is present. When disease progresses beyond stage IIIa, resection is not attempted. On microscopy, disease can be classified into several different morphologies: epithelioid, biphasic, and sarcomatoid. Epithelioid is the most common. If unresectable and symptomatic, patients are treated with a chemotherapy combination or an immunotherapy combination. For a chemotherapy combination, cisplatin is preferred unless contraindicated plus pemetrexed, with or without bevacizumab. Immunotherapy combining a PD1 and a CTLA4 inhibitor with nivolumab and ipilimumab are preferred in the first line, particularly for the sarcomatoid variant. A randomized trial demonstrated superiority for an immunotherapy combination over a chemotherapy combination, with the benefit apparently driven by activity in the sarcomatoid variant. In the second-line setting, a single-agent PD1 inhibitor or a PD1 and CTLA4 inhibitor combination can be used if an immune checkpoint inhibitor was not used in the first line.
References
- Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21(14):2636-44. DOI: https://doi.org/10.1200/JCO.2003.11.136
- Baas P, Scherpereel A, Nowak AK, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial [published correction appears in Lancet. 2021 Feb 20;397(10275):670]. Lancet. 2021;397(10272):375-86. DOI: https://doi.org/10.1016/S0140-6736(20)32714-8