Jan 18, 2022
Test your knowledge of central nervous system cancers and gynecologic cancers with two multiple-choice questions from 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.
Interested in writing questions for the ASCO Self-Evaluation Program (SEP)? Join the 2022 ASCO SEP Item Writing Task Force. Submit your application for the Item Writing Task Force under Volunteer Opportunities on ASCO myConnection. Sign in with your ASCO username and password to view the application and click the sign-up button.
Correct answers are listed at the bottom of the page.
Question 1: Central Nervous System Cancers
A 68-year-old right-handed man presented to the emergency department with his first generalized seizure. A CT of the head showed a lesion in the right frontal lobe. A brain MRI with and without contrast enhancement confirmed a 2 x 2 cm contrast-enhancing lesion in the right frontal lobe. He was started on dexamethasone and levetiracetam. The lesion was resected, and pathology was consistent with glioblastoma that is WHO grade 4, with wild-type IDH and MGMT methylation. The patient had an uneventful recovery from the surgery and presents to your clinic for discussion on the next steps.
Which of the following is the most appropriate next step?
- Radiation therapy, followed by procarbazine, lomustine, and vincristine
- Concurrent radiation therapy and temozolomide, followed by maintenance temozolomide with or without tumor treating fields
- Concurrent radiation therapy and temozolomide without further adjuvant therapy
- Radiation therapy, followed by maintenance temozolomide
Question 2: Gynecologic Cancers
A 66-year-old woman presents with right lower quadrant pain and general abdominal discomfort. A contrast-enhanced CT of the abdomen and pelvis showed a large cystic mass about the central pelvis extending slightly to the left, measuring 10.7 x 12 x 11 cm in size, and a smaller cystic lesion in the right adnexa measuring 5.6 x 3.6 cm. The patient underwent staging laparotomy with bilateral salpingo-oophorectomy, pelvic washings, omentectomy, sigmoid colectomy with colostomy placement, and appendectomy. She received optimal cytoreduction. Postsurgical pathology was positive for high-grade serous ovarian cancer of the left ovary with adjacent organ involvement into the right ovary, omentum, urinary bladder, and sigmoid colon with peritoneal ascitic fluid positive for malignancy. The patient tested negative for somatic or germline BRCA1/2 mutations. She is also negative for homozygous recombinant deficiency (HRD). Her tumor is negative for these mutations and HRD. The patient had a complete response after six cycles of carboplatin, paclitaxel, and bevacizumab.
Which of the following is the most appropriate regimen for the treatment of this patient?
- Maintenance bevacizumab
- Maintenance bevacizumab and olaparib
- Maintenance bevacizumab and niraparib
- Maintenance olaparib
Question 1 Rationale and References
Correct answer: B. Concurrent radiation therapy and temozolomide, followed by maintenance temozolomide with or without tumor treating fields
Rationale: A recent open-label randomized clinical trial added tumor treating fields with maintenance temozolomide after concurrent radiation therapy and temozolomide in patients with newly diagnosed glioblastoma. The trial showed improved progression-free and overall survival compared to adjuvant temozolomide alone. Neither of these studies was placebo controlled. The tumor treating fields consist of low-intensity, alternating electric fields delivered via transducer arrays applied to the scalp.
Reference
- Stupp R, Taillibert S, Kanner A, et al. Effect of tumor-treating fields plus maintenance temozolomide vs maintenance temozolomide alone on survival in patients with glioblastoma: a randomized clinical trial. JAMA. 2017;318:2306-16. DOI: https://doi.org/10.1001/jama.2017.18718. Erratum in: JAMA. 2018;319:1824.
Question 2 Rationale and References
Correct answer: A. Maintenance bevacizumab
Rationale: Patients eligible for maintenance olaparib and bevacizumab include those with an advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in complete or partial response to first-line platinum-based chemotherapy and bevacizumab with HRD-positive status, as defined by either a deleterious or suspected deleterious BRCA mutation and/or genomic instability. The phase III PAOLA-1 trial enrolled 806 women from 11 countries who had newly diagnosed advanced (International Federation of Gynecology and Obstetrics [FIGO] stage III or stage IV) high-grade serous or endometrioid ovarian, fallopian tube, or primary peritoneal cancers that responded to first-line platinum and taxane–based chemotherapy, in combination with bevacizumab. Patients were randomly assigned in a 2:1 ratio to receive either olaparib and bevacizumab maintenance or bevacizumab maintenance alone. In an analysis by BRCA status, the median progression-free survival was 37.2 months in the olaparib group versus 21.7 months in the placebo group (hazard ratio, 0.31). In an analysis by HRD status, the median progression-free survival was 37.2 months in the olaparib group versus 17.7 months in the placebo group (hazard ratio, 0.33). Among patients with HRD-negative tumors, the median progression-free survival was 16.6 months in the olaparib group versus 16.2 months in the placebo group (hazard ratio, 1.0). The addition of maintenance olaparib to bevacizumab in the first-line setting improved progression-free survival significantly in patients with HRD-positive status.
References
- Ray-Coquard I, Pautier P, Pignata S, et al. Olaparib plus bevacizumab as first-line maintenance in ovarian cancer. N Engl J Med. 2019;381:2416-28. DOI: https://doi.org/10.1056/NEJMoa1911361.
- U.S. Food and Drug Administration. FDA Approves Olaparib Plus Bevacizumab as Maintenance Treatment for Ovarian, Fallopian Tube, or Primary Peritoneal Cancers. https://www.fda.gov/drugs/drug-approvals-and-databases/fda-approves-olaparib-plus-bevacizumab-maintenance-treatment-ovarian-fallopian-tube-or-primary. Accessed Jan 28, 2021.