Internal medicine - Clinical oncology(119) Flashcards
INT - 17.1
Who decides to start a complex oncology treatment for a newly diagnosed cancer patient?
A) The surgeon, because the tumor primarily requires resection
B) The oncologist, because he/she knows best about chemotherapy protocols
C) The pathologist, who determines the exact diagnosis using immunohistochemical methods
D) The radiotherapy specialist
E) All of the above
ANSWER
E) All of the above
EXPLANATION
Treatment of newly-diagnosed tumorous patients is decided by an Onko-Team, which consists of a surgeon, an oncologist, a pathologist, a radiotherapist, and a psychologist beeing an expert in psycho-oncology.
INT - 17.3
What is the relationship between dysplasia and cancer?
A) Dysplasia always leads to the development of a cancer.
B) All cancer is preceded by dysplasia.
C) The progression of cancer is dysplasia.
D) A and C.
E) All of the above.
ANSWER
B) All cancer is preceded by dysplasia.
EXPLANATION
Dysplasia means insufficient differentiation and elevated number of mitosis. At precancerous stage, all types of cancer are preceded by dysplasia, but not all dyplasia leads to cancer.
INT - 17.4
At cellular level tumor growth does not depend on the following:
A) time of cell cycle
B) growth fraction (proliferating tumor cell ratio)
C) cell death rate inside the tumor
D) time of duplication of tumor volume
E) apoptosis
ANSWER
E) apoptosis
EXPLANATION
Tumor growth depends on four factors: time of cell cycle, growth fraction (proliferating tumor cell ratio), time to duplicate tumor volume, and tumor cell loss (cell death rate). With these variations, the different behavior of various histologic and primary and metastatic histopathological tumors can be well described.
INT - 17.6
The prognosis of the following tumor was the most significantly improved by combined chemotherapy:
A) Small cell lung cancer
B) Medulloblastoma
C) Seminoma
D) Neuroblastoma
ANSWER
C) Seminoma
EXPLANATION
The cure rate of seminoma with combined chemotherapy after surgery is above 90% if there was no distant metastases. Even if distant metastases are present, cure rate is still above 70%.
INT - 17.7
Chemotherapy before surgery is important for the treatment of the following tumor:
A) Wilms-tumor
B) medulloblastoma
C) Burkitt-lymphoma
D) retinoblastoma
E) Gallbladder cancer
ANSWER
A) Wilms-tumor
EXPLANATION
Prognosis of Wilms tumor was significantly improved by preoperative chemotherapy. The results of course depend on the stage and the histological type (preferred / disadvantageous). In case of stage I-II disease, the relapse-free survival is usually around 90%. Neoadjuvant therapy is also important for other tumors, e.g. esophagus-, rectum-, breast- or bone cancer. For Burkitt-lymphoma, no surgical intervention is used for therapeutic purposes.
INT - 17.8
After a curative surgery, the treatment for the prevention of recurrence:
A) neoadjuvant
B) adjuvant
C) palliative
D) supportive
E) none of the above
ANSWER
B) adjuvant
EXPLANATION
After surgical treatment of a cancer, the treatment used to prevent recurrence is called adjuvant therapy.
INT - 17.9
To evaluate the effectiveness of adjuvant treatment, the following parameter is chosen:
A) The time to relapse
B) Disease-free survival
C) Overall survival
D) All of the above
ANSWER
D) All of the above
EXPLANATION
There are three basic patient-related parameters to evaluate the effectiveness of adjuvant therapy: time to relapse (TR), disease-free survival (DFS), total patient lifetime (“overall Survival “, OS).
INT - 17.10
In case of treatment of cancer patients, improvement of the disease is called:
A) remission
B) stable disease
C) progression
D) refractory disesase
E) none of the above
ANSWER
A) remission
EXPLANATION
Remission means the improvement of the disease. In the case of stable disease, the changes observed during treatment do not change significantly, while in case of deterioration we speak of progression. In refractory state, the disease does not respond to the treatment.
INT - 17.11
Criteria for evaluating the therapeutic response during treatment of cancer patients:
A) Dukes-staging system
B) RECIST-staging system
C) Forrest-staging system
D) Bismuth-staging system
E) All of the above
ANSWER
B) RECIST-staging system
EXPLANATION
Dukes classification is used for the staging of colorectal carcinoma. RECIST (Response Evaluation Criteria In Solid Tumors) is used for evaluating the therapeutic response in solid tumors. In case of a gastroduodenal ulcer disease, Forrest-classification is used to evaluate the bleeding activity of the ulcer. Bismut-classification aims to provide an anatomical description of hilar biliary tract cancers.
INT - 17.12
In oncological clinical studies progression free survival (PFS) is often evaluated. How do you define this term?
A) Progression-Free Survival (PFS) is the time that elapses in a progressive/metastatic tumor from starting treatment (from clinical trial randomization) to repeated tumor growth and/or death of a patient.
B) PFS is the time that elapses from the onset of the therapy of an advanced / metastatic disease (in clinical trials from randomization) to the death of a patient.
ANSWER
A) Progression-Free Survival (PFS) is the time that elapses in a progressive/metastatic tumor from starting treatment (from clinical trial randomization) to repeated tumor growth and/or death of a patient.
EXPLANATION
The FDA (Food and Drug Administration, United States Department of Food and Drug Administration) issued detailed guidelines on the clinical endpoint of oncological clinical trials. Progression-free survival ranges from treatment initiation, i.e. randomization to objective tumor progression or to the patient’s death. (TTP, time-to-pregression: only time to progression is observed, death of patients is not taken into account, censorship of mortality data by terminology.)
INT - 17.13
Definition of overall survival (OS):
A) Overall Survival (OS) is the time that elapses in a progressive / metastatic tumor from starting treatment (from randomization in clinical trials) to repeatedly confirmed tumor growth and / or death of the patient.
B) Overall survival (OS) is the time that elapses from the onset of tumor treatment (in clinical trials from randomization) to the death of a patient.
ANSWER
B) Overall survival (OS) is the time that elapses from the onset of tumor treatment (in clinical trials from randomization) to the death of a patient.
EXPLANATION
The FDA (Food and Drug Administration, United States Department of Food and Drug Administration) issued detailed guidelines on the clinical endpoint of oncology clinical trials. (The Clinical Trial Endpoints for the Approval of Cancer Drugs and Biology, 2007) Overall survival (OS) according to the guidelines, is the time elapsed from randomization (that is, the commencement of a trial after randomized election of patients) until patients’ death from any reason. This is a very realistic endpoint in oncology clinical trials. It is accurate, easy to measure and document, and is therefore a preferred endpoint in oncology clinical trials.
INT - 17.14
The overall response rate (ORR) is used to express the effectiveness of treatment in clinical trials. Which components does the ORR consist of? (CR is the complete response, PR is partial response, SD is stable disease / and PD is progressive disease /.)
A) ORR= CR+PR+ SD + PD
B) ORR= CR+PR+ SD
C) ORR= CR+PR
ANSWER
C) ORR= CR+PR
EXPLANATION
Clinical trials often use the ORR or RR (response rate) expressions for treatment of malignant diseases. The response rate is directly related to the activity of an anticancer drug. The FDA (Food and Drug Administration, US Food and Drug Administration) has issued detailed guidelines with endpoints of clinical trials of oncology which also defines ORR. In general, the ORR is the amount of partial response and complete response. Stable disease (SD) is not part of the response rate.
INT - 17.15
PRO abbreviation is often used in oncology drug development. It is the abbreviation of:
A) Progression Related Outcome
B) Patient Reported Outcome
ANSWER
B) Patient Reported Outcome
EXPLANATION
Patient’s opinion regarding the particular medication has an increasing role in clinical studies of oncology. The information about the patient’s medical condition comes directly from the patient (not interpreted by a doctor or someone else). In clinical trials, such questionnaires are used to measure the effectiveness of an intervention. To collect such data, various quality of life questionnaires are in use.
INT - 17.16
What is the RECIST criteria used for in oncology and in oncological clinical trials?
A) In solid tumors, the response to anticancer treatment in imaging studies is evaluated by these criteria.
B) RECIST relates to the determination of cell surface receptors in solid tumors.
ANSWER
A) In solid tumors, the response to anticancer treatment in imaging studies is evaluated by these criteria.
EXPLANATION
RECIST: Response Evaluation Criteria in Solid Tumors, provides framework how to evaluate therapeutic response in solid tumors using various imaging platforms (CT, MRI, PET-CT). Based on this system we can differentiate among complete response, partial response, stable disease or progression.
INT - 17.17
In ca. 10% of cancer patients, hypercalcaemia occurs due to tumor cells producing materials. Such materials are the following, except:
A) production of parathormon-like peptide
B) calcitonin
C) active metabolits of Vitamin-D
D) prostaglandins
E) TGF-α és TGF-β
ANSWER
B) calcitonin
EXPLANATION
Increased calcitonin production may occur in medullary carcinomas of thyreoid gland, or can be ectopic in many tumors, such as in small celllung cancer, breast cancer and leukemia. Calcitonin does not cause hypercalcaemia, although, there is also no exact data that it would lead to hypocalcaemia in a tumorous patient.
INT - 17.18
Which gene’s defect is the most common in human tumors?
A) c-raf
B) c-myc
C) K-ras
D) p53
E) c-fos
ANSWER
D) p53
EXPLANATION
Error of p53 (mutations, deletions, protein inactivation) is the most common.
INT - 17.19
What is the meaning of MDR?
A) minimal disease residue
B) multiple drug resistance
C) maximal dose rate
D) mesenchymal disease risk
E) medulloblastoma gene receptor
ANSWER
B) multiple drug resistance
EXPLANATION
Multidrug resistance means that there are proteins (plasma membrane transporters - MDR1, MRP1) which are able to “pump out” the chemotherapeutic agents from cells, including tumor cells, to hinder effective intracellular concentrations. For certain drugs, it is recommended to determine the MDR1 activity to reach the expected therapeutic effect.
INT - 17.20
For which chemotherapeutic agent is the citrovorum factor or folic acid used as a “rescue” compound (for the protection of normal tissues and thus high dosage chemotherapy)?
A) methotrexat
B) bleomycin
C) cyclophosphamid
D) adriamycin
E) vincristin
ANSWER
A) methotrexat
EXPLANATION
Methotrexate ultimately reduces the level of reduced folate, thereby, level of thymidine nucleotides and / or purine nucleotides. This effect leading to cytotoxicity is related to the plasma concentration of the agent. Leucovorin (citrovorum factor, folic acid), provided to the patient after treatment, can rescue normal tissues without diminishing the antitumor effect. This protection allows the administration of methotrexate at high doses. (The folic acid is also co-administered with 5-fluorouracils.) In combinations, there are many variations of the order and dose of these drugs.
INT - 17.21
Mesna may reduce the toxic damage of the bladder. Which cytostatic agent is it used for?
A) 5-fluorouracil
B) adriamycin
C) cisplatin
D) cyclophosphamid
E) methotrexat
ANSWER
D) cyclophosphamid
EXPLANATION
Cyclophosphamide is activated in the body, its alkylating metabolite is the anti-tumor phosphoramidic mustard and acrolein which causes bladder irritation. At high doses, severe haemorrhagic cystitis may occur which can be prevented by mesna (sodium 2-mercaptoethanesulfonate). Mesna neutralizes the harmful metabolite and does not affect the anti-tumor effect. Cyclophosphamide treatment may increase the risk of developing bladder cancer.
INT - 17.22
The following side effects may occur immediately or early after cytotoxic therapy except (indicate the exception):
A) nausea / vomiting
B) urocystitis
C) renal failure
D) phlebitis
E) azoospermia
ANSWER
E) azoospermia
EXPLANATION
Oncological emergency cases include cardiovascular, haematological, metabolic and neurological complications. Azoospermia can be a late side effect.
INT - 17.23
Which phase of the cell cycle is affected by taxane type cytostatics?
A) G0
B) G1
C) S
D) G2
E) M
ANSWER
E) M
INT - 17.24
What is the machanism of action of camptothecin cytostatics (irinotecan, topotecan)?
A) inhibits the depolymerization of microtubules
B) topoizomerase II. inhibitors
C) topoizomerase I. inhibitors
D) Inhibition of DNA function and cell division in phase M
ANSWER
C) topoizomerase I. inhibitors
EXPLANATION
They block the DNA replication by blocking the topoisomerase I.
INT - 17.25
The following is valid for antimitotic chemotherapeutic drugs:
A) causes covalent crosslinking of the two polynucleotide chains in the dual spiral of DNA
B) they inhibit DNA synthesis through the inhibition of important enzymes of purine or pyrimidine synthesis.
C) they inhibit the polymerization of tubulins, i.e. the formation of mitotic spindles.
D) They inhibit the depolymerization of tubulins, i.e. blocking the mitotic spindle.
E) C and D
ANSWER
E) C and D
EXPLANATION
Antimitotic chemotherapeutic drugs inhibit the polymerization of tubulins, and so, the formation of mitotic spindles. They also inhibit the depolymerization of tubulins, i.e. block the mitotic spindle.
INT - 17.26
Which compound belongs to the strong opiates?
A) codein
B) oxycodon
C) tramadol
D) dextropropoxyphen
ANSWER
B) oxycodon
EXPLANATION
Fentanyl, Hydromorphone and oxycodon are the strongest opiates in order.
INT - 17.27
Targeted therapies for treatment of solid tumors, except (indicate the exception):
A) adalimumab
B) imatinib
C) sorafenib
D) cetuximab
E) sunitinib
ANSWER
A) adalimumab
EXPLANATION
Adalimumab is a human monoclonal antibody used to treat inflammatory bowel disease, and has no indications in treatment of solid tumor. B-E responses are targeted treatment options for solid tumors (imatinib - gastrointestinal stroma tumor, sorafenib - hepatocellular carcinoma, kidney cancer, cetuximab - colorectal carcinoma, non-small cell lung cancer, sunitinib kidney cancer, gastrointestinal stromal tumor).
INT - 17.28
CA-19-9 tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreas cancer
ANSWER
E) pancreas cancer
EXPLANATION
In cases of pancreatic cancer, the CA 19-9 value is often elevated.
INT - 17.29
CA-15-3 tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
D) breast cancer
EXPLANATIONThe most specific tumor marker for breast cancer is CA 15-3. Therefore, they are followed up.
INT - 17.30
AFP (alfa-foeto-protein) tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
B) hepatocellular carcinoma
EXPLANATION
In case of hepatocellular carcinoma, AFP value is often elevated.
INT - 17.31
CA-125 tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
A) ovarian cancer
EXPLANATION
CA-125 tumor marker is often elevated in gynecological tumors, especially in ovarian cancer.
INT - 17.32
β-HCG tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
C) testicular cancer
EXPLANATION
In some of testicular cancer, beta-HCG (= human choriogonadotropic hormone) is elevated, and can be used for monitoring the disease.
INT - 17.33
In case of prostate cancer, which of the following tumor markers should be followed?
A) β-HCG
B) CEA
C) PSA
D) CA-125
ANSWER
C) PSA
EXPLANATION
PSA, i.e. prostate specific antigen is a specific marker of prostate cancer, most of the times, it is sensitive to the development and change of the disease.
INT - 17.34
Which factor is not used for monitoring or as prognostic factor in tumors?
A) CEA
B) PSA
C) β-HCG
D) TSH
E) p53
ANSWER
D) TSH
EXPLANATION
TSH can not be considered to be a tumor marker. The others are used as tumor markers, however, opinions about their advantage - specificity, sensitivity - vary considerably.
INT - 17.35
What is the most common histological type of malignant oesophageal cancer?
A) leiomyosarcoma
B) epithelial carcinoma
C) adenocarcinoma
D) rhabdomyosarcoma
E) melanoma
ANSWER
B) epithelial carcinoma
EXPLANATION
80-90% of malignant esophageal tumors are squamous-cell carcinoma.
INT - 17.36
What is the most common primary tumor site in Krukenberg tumor?
A) breast cancer
B) gallbladder cancer
C) rectum cancer
D) pancreas cancer
E) gastric cancer
ANSWER
E) gastric cancer
EXPLANATION
Krukenberg tumor (metastases in the ovaries) is the result of a gastric cancer in ca. 75% of the cases, the rest is in majority a metastasis of colon cancer.
INT - 17.37
In case of haematogenous dissemination, the following tumors usually give a pulmonary metastases first, except one type of tumor:
A) gastric cancer
B) breast cancer
C) renal cancer
D) chorionepithelioma
E) osteosarcoma
ANSWER
A) gastric cancer
EXPLANATION
Because of venous discharge, in the first wave of hematogenous spread of gastric cancer, liver metastases are typical. (However, it is important to take account of the possibility of “unusual” lymphogenic metastasis over the diaphragm, eg. the supraclavicular lymph node.)
INT - 17.40
Which drug was the first approved „targeted therapy” in the treatment of hepatocellular carcinoma?
A) sorafenib
B) bevacizumab
C) gefitinib
D) vandetanib
E) ipilimumab
ANSWER
A) sorafenib
EXPLANATION
In the treatment of hepatocellular carcinoma approving the first „targeted therapy”was a real breakthrough. This drug is called sorafenib, which was approved under the name of Nexavar.
INT - 17.41
According to clinical studies, the sorafenib treatment in patients diagnosed with primary hepatic cancer (hepatocellulray carcinoma),increases the overral survival. Is this true or false?
A) true
B) false
ANSWER
A) true
EXPLANATION
According to the results of the international,multicentric, double blind, randomized phase III study SHARP, treatment with sorafenib in the case of patients with advanced hepatocellular cancer, (and ECOG 0-2 status), resulted in significant increase of overal survival.
INT - 17.42
Choose the correct answer.
A) The mortality of colon cancer is constantly increasing.
B) The mortality of colon cancer has been decreasing since the introduciton of effective chemotherapy.
C) The mortality of colon cancer was rapidly increasing between 1965 and 2000, since then it has been stagnant.
D) The mortality of colon cancer hasn’t changed significantly in the past few decades.
E) In first world countries,colon cancer has the highest mortality rate of all cancers
ANSWER
C) The mortality of colon cancer was rapidly increasing between 1965 and 2000, since then it has been stagnant.
EXPLANATION
The mortality of colorectal cancer increased rapidly between 1965 and 2000, since then it has been stagnant..
INT - 17.43
Chemotherapy drugs used in the treatment of colorectal cancer, except:
A) 5-fluorouracil
B) capecitabine
C) oxaliplatin
D) irinotecan
E) docetaxel
ANSWER
E) docetaxel
EXPLANATION
Docetaxel therapyis currently not applied in the treatment of colorectal cancer.
INT - 17.44
Treatment option in the therapy of rectal cancer:
A) total mesorectal excision
B) neoadjuvant chemotherapy
C) adjuvant chemotherapy
D) VEGF inhibitor drugs
E) all of the above
Answer
E) all of the above
EXPLANATION
All of above are part of the treatment of the rectal cancer respectively.
INT - 17.45
In which malignant disease ”DNA mismatch repair error” is the most frequent?
A) Li–Fraumeni-sydrome
B) MEN-2 syndrome
C) retinoblastoma
D) hereditary, non polyposis colon cancer (HPNCC)
E) Wilms-tumor
ANSWER
D) hereditary, non polyposis colon cancer (HPNCC)
EXPLANATION
The prototype disease of mismatch-repair-error is the HNPCC: hereditary non-polyposis colorectal cancer (the affected genes are the hMSH2, PMS family – hMLH1, hPMS1, hPMS2, hMSH3, hMSH6 genes). In Li-Fraumeni syndrome the mutation is in the p53 gene, in retinoblastoma in the RB1 gene, in MEN-2 syndrome in the Ret gene, and in the case of Wilms-tumor in the WT1 gene.
INT - 17.46
Which of the following malignant cancers don’t ususally metastatize to the bones?
A) thyroid cancer
B) breast cancer
C) renal cancer
D) colon cancer
E) prostate cancer
ANSWER
D) colon cancer
EXPLANATION
Colon cancer rarely metastatizes to the bones, even in it’s disseminated form, however bone pain, or even bone fracture can be the first sypmtom of the other tumors.
INT - 17.47
Correct statements regarding the neuroendocrine tumor (NET), except:
A) Neuroendocrine tumors are rare entities
B) The incidence of neuroendocrine tumors has been increasing in the past 30 years.
C) Most of the neuroendocrine tumors are classified as “non-functioning” types.
D) Neuroendocrine tumor most typically affects the pancreas.
E) Carcinoid syndrome is present in less than 10% of all neuroendocrine tumors.
ANSWER
D) Neuroendocrine tumor most typically affects the pancreas.
EXPLANATION
Neuroendocrine tumors are rare entities, alhough, the incidency has increased five times greater in the last 30 years, and has been increasing year by year. The most commonly affected site are the intestines. Most of them are non-functioning types as their secreted peptides or hormones do not manifest in clinical symptoms, like carcinoid sydrome which is only present in less than 10% of neuroendocrine tumors.
INT - 17.48
The following malignant tumors,during hematogenous spreading metastatize at first to the liver, except:
A) gastric cancer
B) colon cancer
C) panreatic cancer
D) adrenal gland carcinoma
E) gallblader cancer
ANSWER
D) adrenal gland carcinoma
EXPLANATION
Along the the anatomy of the venous system, tumors of the adrenal gland metastatize to the lungs first, meanwhile, the other tumors usually metastatize to the liver in the begining.
INT - 17.49
Of the following factors which ones should be measured-calculating the Notthingham Prognostic Index?
A) size of the tumor in centimeter
B) histological grade
C) lymph node status
D) all of the above three factors
ANSWER
D) all of the above three factors
EXPLANATION
Notthingham Prognostic Index (NPI) refers to the long-term prognosis of breast cancer. It is a calculated value which takes the histological characteristics of the tumor into account, providing information on the long-term prognosis and the risk of relapse of breast cancer. It takes account of the size of the tumor, the lymph node status, and the histological grade. Calculating the NPI the size of tumour in centimeter is multiplied by 0,2, then the histological grade is added to it, as well as the number referring to the lymh node status: 1 if there are not lymph node metastasis; 2 if metastases are confirmed in 1, 2, or 3 lymph nodes; 3 if metastases are confirmed in four or more lymph nodes.
INT - 17.50
During the histological evaluation of breast cancer we use the „NPI” abbreviation. What does it stand for?
A) Norfolk Predictive Index
B) Notthingam Prognostic Index
ANSWER
B) Notthingam Prognostic Index
EXPLANATION
NPI is the abbreviation of Notingham Prognostic Index which is a calculated value, that relate to thelong-term prognosis of breast cancer.
INT - 17.51
In the case of breast cancer which NPI score is considered as poor prognosis?
A) below 3,14
B) above 5,4
ANSWER
B) above 5,4
EXPLANATION
If the Nottingham Prognostic Index is below 3, we see excellent prognosis, there is long–term survival perspetive among breast cancer patients after surgery. Below 3,14 the prognosis is good; between 3,14 and 5,4 we talk about moderate long-term prognosis; above 5,4 the life expectancy is poor with high chance of relapse.
