Oct 22, 2021
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.
Find more self-assessment questions at ASCO Education.
Correct answers are listed at the bottom of the page.
Question 1: Genitourinary Cancers
A 65-year-old woman with a 40 pack-year smoking history had intermittent hematuria for 1 year. Her urine cytology was initially negative, and over the past 6 months, urine cytology was positive. Cystoscopy by urology revealed a fungating mass. Biopsy was positive for urothelial cancer, but deep muscle was not present. Physical examination revealed obesity and hypertension, no jaundice, and no hepatosplenomegaly. Labs revealed anemia with hemoglobin of 10.6 g/dL and creatinine of 1.3 mg/dL.
What is the most appropriate next diagnostic step?
- CT scan of the abdomen and pelvis
- Repeat cystoscopy with transurethral resection of bladder tumor (TURBT)
- Urine cytology with fluorescent testing for DNA
- Follow-up cystoscopy in 3 months
Question 2: Lymphomas
A previously healthy 46-year-old man presents for a consultation after removal of colonic mass. He underwent laparoscopic right hemicolectomy 3 weeks ago when he presented with intussusception, and has now fully recovered from the surgery. Pre-operative CT scan had shown a 5-cm mass in the cecum with an adjacent 3-cm pericolic lymph node. The pathology report describes a high-grade lymphoma with medium-size and highly monomorphic cells which was 100% positive for Ki-67, and positive for CD20, CD10, and BCL6. Additional fluorescence in situ hybridization tests are positive for MYC-IGH fusion, and negative for IGH-BCL2 fusion or BCL6 rearrangement. Complete blood count, lactate dehydrogenase, renal function, and HIV serology are normal. A combined PET-CT scan and bone marrow biopsy show no evidence of lymphoma.
What is the most appropriate treatment plan for this patient?
- Three cycles of R-CHOP chemotherapy followed by radiation therapy
- Three cycles of R-CODOX-M chemotherapy, including IT prophylaxis
- Six cycles of R-CHOP chemotherapy
- Adjuvant radiation therapy to right lower quadrant
Question 1 Rationale and References
Correct Answer: B. Repeat cystoscopy with transurethral resection of bladder tumor (TURBT)
Rationale: In transurethral resection (TUR) specimens, the superficial and deep areas of the tumor should be sent to the pathology laboratory separately, in case the outcome will impact treatment decisions. If random biopsies of the flat mucosa are taken, each biopsy specimen of the flat mucosa should also be sent separately. In radical cystectomy, bladder fixation must be carried out as soon as possible. The pathologist must open the specimen from the urethra to the bladder dome and fix the specimen in formalin. In some circumstances this procedure can also be performed by the urologist.
In a female cystectomy specimen, the length of the urethral segment removed en bloc with the specimen should be checked, preferably by the urologic surgeon. Specimen handling should follow the general rules as published by a collaborative group of pathologists and urologists. It must be stressed that it may be very difficult to confirm the presence of a neoplastic lesion using gross examination of the cystectomy specimen after TUR or chemotherapy, so the entire retracted or ulcerated area should be included. Traditionally, radical cystectomy was recommended for patients with muscle invasive bladder cancer (MIBC) T2-T4a, N0-Nx, M0. Evidence of presence of deep muscle should be present to adequately make a diagnosis of muscle-invasive disease.
- Babjuk M, Böhle A, Burger M, et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol. 2017;71:447-61.
Question 2 Rationale and References
Correct Answer: B. Three cycles of R-CODOX-M chemotherapy, including IT prophylaxis
Rationale: This patient had a localized and completely resected, sporadic Burkitt lymphoma (BL) of the intestine—a scenario more common in the pediatric population, associated with excellent prognosis. Despite lack of residual gross disease, the patient should receive therapy appropriate for low-risk BL, which may include three cycles of CODOX-M regimen (without IVAC). Neither R-CHOP nor radiation therapy are adequate for this high-grade lymphoma. Dose-intense combinations like CODOX-M/IVAC or hyper-CVAD, as well as dose-adjusted EPOCH, in combination with rituximab, remain the mainstay of therapy. The abbreviated course of R-CODOX-M offers a good balance of efficacy and toxicity.
- Jacobson C, LaCasce A. How I treat Burkitt lymphoma in adults. Blood. 2014;124:2913-20.
- NCCN Clinical Practice Guidelines in Oncology. B-cell lymphomas, version 2.2017.
Originally published November 2019; reviewed and updated October 2021.