Apr 17, 2023
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 from ASCO-SEP.
Learn more about ASCO’s Educational products, such as the 2022 ASCO-SEP Digital Subscription, which includes the digital book, access to education courses and virtual meeting-related content, plus over 1,000 practice questions in the Question Bank. Oncology trainees and training program directors can visit Education Essentials for Oncology Fellows (EEOF) to learn more and register for the 2022-2023 cycle.
Correct answers are listed at the bottom of the page.
Question 1: Genitourinary Cancer
A 68-year-old woman presents with gross hematuria and is diagnosed with muscle-invasive urothelial bladder cancer. She receives neoadjuvant dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) chemotherapy and undergoes radical cystectomy. She is found to have residual pT3 disease invasive into the extravesical fat. On surveillance imaging 6 months later, new retroperitoneal lymphadenopathy and bilateral lung metastases are detected. She receives pembrolizumab and 3 months later, restaging scans show multiple new hepatic metastases measuring between 3 and 4 cm. Next-generation sequencing shows that she does not harbor a mutation or fusion in FGFR2 or FGFR3. Her Karnofsky performance status is 90%. She requests the most aggressive treatment option possible.
Which of the following should you recommend now?
- Continue pembrolizumab
- Enfortumab vedotin
- Erdafitinib
- Sacituzumab govitecan
Question 2: Gynecologic Cancer
A 72-year-old woman is referred for evaluation and management 3 weeks after undergoing total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and surgical staging to treat poorly differentiated carcinoma of the endometrium. Her uterine wall thickness was 12 mm, with 10 mm of tumor invasion and evidence of lymphovascular space invasion. All 14 pelvic and para-aortic lymph nodes were negative, and there was no cervical, ovarian, or fallopian tube involvement of the disease. Peritoneal washings were negative for malignant cells.
Which of the following is the most appropriate next step?
- Carboplatin and paclitaxel chemotherapy
- Megestrol acetate therapy
- Whole pelvis radiation therapy
- Vaginal brachytherapy
Question 1 Rationale and Reference
Correct answer: B. Enfortumab vedotin
Rationale: Enfortumab vedotin is the best choice for this patient, as it contributes a significant overall survival benefit in a randomized phase 3 controlled trial for this exact setting. Although pembrolizumab can be continued, delayed responses are not common, and this patient now harbors liver metastases, which tend to confer a worse prognosis and lower response rates to immuno-oncologic therapy. This patient would need to have a mutation or fusion in FGFR2 or FGFR3 to be eligible for erdafitinib. Sacituzumab govitecan is now FDA approved on the accelerated pathway; however, overall survival benefit has yet to be established.
Reference
- Powles T, Rosenberg JE, Sonpavde GP, et al. Enfortumab vedotin in previously treated advanced urothelial carcinoma. N Engl J Med. 2021;384(12):1125-35. DOI: https://doi.org/10.1056/NEJMoa2035807
Question 2 Rationale and References
Correct answer: B. Whole pelvis radiation therapy
Rationale: This patient has a tumor invading more than half of the myometrium; thus, her disease is considered stage IB by TNM. She has two risk factors—lymphovascular invasion and poorly differentiated histology—further stratifying her as a high-risk patient. The GOG 249 trial showed no superiority of vaginal cuff brachytherapy plus chemotherapy compared with pelvic radiation therapy in patients with stage I endometrioid histology and high-intermediate risk criteria. Acute toxicity was greater with vaginal brachytherapy plus chemotherapy; late toxicity was similar. Pelvic radiation therapy alone remains an effective, well-tolerated, and appropriate adjuvant treatment in high-risk early-stage endometrial carcinomas of all histology. Hormonal therapy is not an appropriate adjuvant therapy for early-stage high-risk endometrial cancer.
References
- Randall ME, Filiaci V, McMeekin DS, vet al. Phase III Trial: Adjuvant Pelvic Radiation Therapy Versus Vaginal Brachytherapy Plus Paclitaxel/Carboplatin in High-Intermediate and High-Risk Early Stage Endometrial Cancer. J Clin Oncol. 2019 Jul 20;37(21):1810-18. DOI: https://doi.org/10.1200/JCO.18.01575
- National Comprehensive Cancer Network. NCCN Guidelines for Uterine Neoplasms V.1.2022 – Interim on 08/14/21. Accessed on 7 March 2023.