Study Guide Chapter 8: Lower Gastrointestinal Cancers

Question 1

1. What percentage of anal canal cancer patients present with extrapelvic visceral metastasis?
   A. <5 %
   B. 10 %
   C. 20 %
   D. 25 %

Answer 1

1. The correct answer is A. A minority of patients present with extrapelvic visceral metastases. When present, these lesions occur most commonly in the liver and lungs. Of note, involvement of para-aortic lymph nodes constitutes M1 disease. Minsky BD, Welton ML, Pineda CE, Fisher GA. Cancer of the anal canal. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips textbook of radiation oncology. 3rd ed. Philadelphia: Elsevier Saunders; 2010. p. 870–82.

Question 2

2. Pelvic lymph node metastases are present in what percentage of anal cancer patients at time of diagnosis?
   A. 10 %
   B. 20 %
   C. 30 %
   D. 40 %

Answer 2

2. The correct answer is C. Pelvic LNs are involved in 30 % of patients at presentation. Minsky BD, Welton ML, Pineda CE, Fisher GA. Cancer of the anal canal. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips textbook of radiation oncology. 3rd ed. Philadelphia: Elsevier Saunders; 2010. p. 870–82.

Question 3

3. According to 7th edition of the AJCC Cancer Staging Manual, a patient with anal canal cancer with a metastasis in a R inguinal lymph node and a L internal iliac LN would be staged as:
   A. N1
   B. N2
   C. N3
   D. M1

Answer 3

3. The correct answer is B. N2 disease is defined as “metastasis in unilateral internal iliac and/or inguinal lymph node(s).” Having bilateral internal iliac lymph node involvement or bilateral inguinal lymph node involvement would be defined as N3 disease. Edge SB, Byrd DR, Compton CC, et al., editors. Anus. AJCC cancer staging handbook. 7th ed. New York: Springer; 2010.

Question 4

4. What is the 5-year overall survival of a patient with stage I anal cancer ?
   A. 95 %
   B. 85 %
   C. 80 %
   D. 75 %

Answer 4

4. The correct answer is B. The 5-year overall survival of stage I anal cancer is 85 %. For stages II–IV, it is 75 %, 50 %, and 5 %, respectively. Minsky BD, Welton ML, Pineda CE, Fisher GA. Cancer of the anal canal. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips textbook of radiation oncology. 3rd ed. Philadelphia: Elsevier Saunders; 2010. p. 870–82.

Question 5

5. According to the 7th edition of AJCC Cancer Staging Manual, a patient with anal canal cancer with a metastasis in a R inguinal lymph node and a perirectal lymph node would be staged as:
   A. N1
   B. N2
   C. N3
   D. M1

Answer 5

5. The correct answer is C. N3 disease is defi ned as “metastasis in perirectal and inguinal lymph nodes and/or bilateral internal iliac and/or inguinal lymph nodes.” Edge SB, Byrd DR, Compton CC, et al., editors. Anus. AJCC cancer staging handbook. 7th ed. New York: Springer; 2010.

Question 6

6. What was the pathological complete response rate seen in patients undergoing
   chemoRT, then surgery, as reported by Nigro et al.?
   A. <20 %
   B. 30–40 %
   C. 60–70 %
   D. >85 %

Answer 6

6. The correct answer is D. Ten years after fi rst publishing his protocol of 5-FU, mitomycin C, and radiation, follow-up data of 104 patients undergoing preoperative chemoRT, then surgery, showed pathological complete response in 97 of 104 patients (93 %). This high pathological complete response rate pioneered chemoRT as a viable treatment option, precluding the need for abdominoperineal resection. Nigro ND et al. An evaluation of combined therapy for squamous cell cancer of the anal canal. Dis Colon Rectum. 1984;27:763–6.

Question 7

7. RTOG 98-11 compared mitomycin-C-based conventional chemoRT to induction 5-FU/cisplatin followed by chemoRT with 5-FU/cisplatin. It found a significant improvement in which of the following:
   A. Overall survival favoring the induction arm
   B. Progression-free survival favoring the mitomycin-C-based chemoRT arm
   C. Colostomy-free rate favoring the mitomycin-C-based chemoRT arm
   D. Local-regional failure rate favoring the induction arm

Answer 7

7. The correct answer is C. Six hundred eighty-two patients with anal cancer were randomized to receive either (1) concurrent fl uorouracil and mitomycin with radiotherapy (45–59 Gy) or (2) induction fl uorouracil and cisplatin with radiotherapy starting on day 57. With a median follow-up of 2.5 years, there was no significant benefit in 5-year disease-free survival, overall survival, local-regional failure, or the distant metastasis rate. The cumulative rate of colostomy was significantly improved in the mitomycin-C arm (10 % vs. 19 %, p = 0.02). There was increased severe hematologic toxicity in the mitomycin arm ( p < 0.001). Ajani JA et al. Fluorouracil, mitomycin, and radiotherapy vs. fluorouracil, cisplatin, and radiotherapy for carcinoma of the anal canal. JAMA. 2008;299(16): 1914–21.

Question 8

8. According to RTOG 05-29, what dose would be prescribed for a 3.0 cm anal canal primary and an involved inguinal lymph node measuring 3.5 cm?

A. 54 Gy to the primary PTV and 54 Gy to the involved lymph node over 30 fractions

B. 54 Gy to the primary PTV and 50.4 Gy to the involved lymph node over 30 fractions

C. 50.4 Gy to the primary PTV and 50.4 Gy to the involved lymph node over 28 fractions

D. 50.4 Gy to the primary PTV and 45 Gy to the involved lymph node over 28 fractions

Answer 8

8. The correct answer is A. This patient has a T2N2 primary. According to RTOG 0529, for N+ disease the primary lesion would be prescribed a dose of 54 Gy over 30 fractions. Because the involved lymph node is greater than 3 cm in size, it would also receive a dose of 54 Gy over 30 fractions. If the lymph node were less than 3 cm in size, it would be prescribed a dose of 50.4 Gy. Kachnic L et al. RTOG 0529: a phase II study of dose-painted IMRT (DP-IMRT), 5-Fluorouracil, and mitomycin-C for the reduction of acute morbidity in anal cancer. Int J Radiat Oncol Biol Phys. 2009;75:s5.

Question 9

9. According to 7th edition of the AJCC Cancer Staging Manual, a patient with a 4 cm rectal adenocarcinoma, 8 cm from the anal verge only invading into, but not through the muscularis propria, with one enlarged lymph node (1.5 cm) on endoscopic ultrasound, would be staged as:

A. T1 N1 Mx

B. T2 N1 Mx

C. T2 N2 Mx

D. Not enough information provided

Answer 9

9. The correct answer is B. According to the 7th edition of AJCC staging, invasion into the muscularis propria constitutes T2 disease. Invasion through the muscularis propria and into pericolorectal tissues constitutes T3 disease. One enlarged lymph node would be N1 disease, which is defined as metastasis in 1–3 regional lymph nodes. Size of the primary is not part of the staging criteria for rectal cancer. Edge SB, Byrd DR, Compton CC, et al., editors. Colon and rectum. AJCC cancer staging handbook. 7th ed. New York: Springer; 2010.

Question 10

10. The German Rectal Cancer Study (CAO/ARA/AIO-94) comparing preopera-tive versus postoperative chemoradiation for rectal cancer found:

A. At a median f/u of 11 years, OS was improved for neoadjuvant chemoRT compared to adjuvant chemoRT.

B. Long-term toxicity was worse in the neoadjuvant chemoRT arm compared to the adjuvant arm.

C. At a median f/u of 11 years, there was no difference in local recurrence.

D. More patients were converted to sphincter-preserving surgeries in the neoadjuvant chemoRT arm.

Answer 10

10. The correct answer is D. The German Rectal Cancer Study randomized 823 patients with cT3–T4 or cN+ rectal cancers to surgery (TME) followed by chemoRT (55.8 Gy) and 4 cycles of additional bolus 5-FU versus preoperative chemoRT (50.4 Gy) followed by TME followed by an additional 4 cycles of bolus 5-FU. In the initial report (2004) with a median follow-up of 3.8 years, preoperative chemoRT was found to decrease local failure (6 % vs. 13 %, p = 0.006). There was no difference in overall or disease-free survival. More patients were converted to sphincter-preserving surgeries in the neoadjuvant chemoRT arm (39 % vs. 19 %). The latest update published in 2012 reported results with a median follow-up of 11 years. Local recurrence was decreased in the neoadjuvant chemoRT arm (7.1 vs. 10.1 %, p = 0.048). There was still no difference in overall survival between the arms. The overall rates of acute and long- term side effects were lower in the neoadjuvant arm, especially with respect to acute and chronic diarrhea and the development of strictures at the anastomotic site. Sauer et al. Preoperative versus postoperative chemoradio- therapy for rectal cancer. N Engl J Med. 2004 Oct 21;351(17):1731–40. Sauer et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012 Jun 1;30(16): 1926–33.

Question 11

11. In the initial report of the German Rectal Cancer Study, what was the pathological complete response rate seen in those patients that underwent preoperative chemoRT?

A. 5 %

B. 8 %

C. 12 %

D. 15 %

Answer 11

11. The correct answer is B. The German Rectal Cancer Study randomized 823 patients with cT3–T4 or cN+ rectal cancers to surgery (TME) followed by chemoRT (55.8 Gy) and 4 cycles of additional bolus 5-FU versus preoperative chemoRT (50.4 Gy) followed by TME, followed by an additional 4 cycles of bolus 5-FU. Of those patients that were randomized to preoperative chemoRT prior to total mesorectal excision for rectal cancer, 8 % experienced a pathologi- cal complete response. Sauer et al. Preoperative versus postoperative chemora- diotherapy for rectal cancer. N Engl J Med. 2004 Oct 21;351(17):1731–40.

Question 12

12. In the initial report of the German Rectal Cancer Study, what percentage of patients initially thought to require abdominoperineal resection were able to undergo sphincter-preserving surgery?

A. 19 %

B. 26 %

C. 39 %

D. 45 %

Answer 12

12. The correct answer is C. The German Rectal Cancer Study randomized 823 patients with cT3–T4 or cN+ rectal cancers to surgery (TME) followed by chemoRT (55.8 Gy) and 4 cycles of additional bolus 5-FU versus preoperative chemoRT (50.4 Gy) followed by TME followed by an additional 4 cycles of bolus 5-FU. Of the 415 patients randomized to preoperative chemoRT, 116 were thought to require abdominoperineal resection. Preoperative chemoRT was able to decrease the need for APR, and 45 of these patients (39 %) were able to undergo sphincter-preserving surgery. Sauer et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004 Oct 21;351(17):1731–40.

Question 13

13. Extending radially outwards from the lumen of the rectum, the correct order of tissue layers is:

A. Lamina propria, submucosa, muscularis propria, serosa

B. Lamina propria, muscularis propria, submucosa, serosa

C. Serosa, lamina propria, submucosa, muscularis propria

D. Muscularis propria, serosa, lamina propria, submucosa

Answer 13

13. The correct answer is A. Depth of invasion corresponds to T stage. Invasion of the submucosa is T1, invasion into the muscularis propria is T2, and invasion through and beyond the muscularis propria is T3. The serosa is the outermost layer of the rectum. Unlike the esophagus, there is no adventitia in the rectum. Edge SB, Byrd DR, Compton CC, et al., editors. Colon and rectum. AJCC cancer staging handbook. 7th ed. New York: Springer; 2010.

Question 14

14. A 65-year-old gentleman with good performance status is diagnosed with a pT2 N1 rectal adenocarcinoma, 7 cm from the anal verge. He is set to start adjuvant chemoradiation. Which of the following is the most established systemic therapy option?

A. Cisplatin and CI 5-FU

B. Cisplatin and bolus 5-FU

C. CI 5-FU

D. CI 5-FU + irinotecan

Answer 14

14. The correct answer is C. Six hundred sixty patients with stage II–III rectal cancer received either bolus or protracted venous infusion of fluorouracil with concurrent postoperative radiation. After completing postoperative chemoRT, they were subsequently randomized to receive either higher-dose fl uorouracil alone or fluorouracil + semustine. With a median follow-up of 46 months, those patients that received CI 5-FU had an increased time to relapse and improved survival (70 % vs. 60 %, p = 0.005). Tumor relapse and distant metastases were also decreased. The addition of semustine provided no additional benefi t. O’Connell MJ et al. Improving adjuvant therapy for rectal cancer by combining protracted-infusion fluorouracil with radiation therapy after curative surgery. N Engl J Med. 1994;331(8):502–7.

Question 15

15. In which of the following rectal cancer studies was total mesorectal excision (TME) required?

A. Polish rectal cancer study

B. MRC07

C. Swedish rectal cancer trial

D. Dutch CKVO trial

Answer 15

15. The correct answer is D. In the Polish rectal cancer study, TME was required only for distal rectal tumors. Not all, but 92 % of patients underwent TME in the MRC CR 07 trial. In the Swedish rectal cancer trial, TME was not required. The Dutch CKVO trial randomized 1,861 patients with resectable rectal cancer to either preoperative RT (5Gy × 5) followed by TME or TME alone. In the initial report, the rate of local recurrence at 2 years was 2.4 % in the RT+TME 8 Lower Gastrointestinal Cancers arnmayer@uni-mainz.de224 arm versus 8.2 % in the TME-alone arm. Bujko et al. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg. 2006 Oct;93(10):1215–1523. Kapiteijn et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;30:345(9):638–46. Sebag-Montefiore D et al. Preoperative radio- therapy versus selective postoperative chemoradiotherapy in patients with rec- tal cancer (MRC CR07 and NCIC-CTG C0616): a multicentre, randomized trial. Lancet. 2009;373(9666):811–20.

Question 16

16. A 68-year-old woman with a 4 cm T3N1 rectal adenocarcinoma, 8 cm from the anal verge, presents for consideration of definitive treatment. According to results of the MRC CR07 trial:

A. There is a survival advantage for preoperative chemotherapy and radiation versus adjuvant chemotherapy and radiation for patients with a positive margin.

B. Preoperative chemotherapy and radiation reduces local recurrence and disease-free survival compared to selective adjuvant chemotherapy and radiation.

C. Short-course preoperative radiation (25 Gy over 5 fractions) improves local recurrence rates and disease-free survival compared to selective adjuvant chemotherapy and radiation.

D. Adjuvant chemotherapy and radiation was able to compensate for a positive margin with respect to local control and disease-free survival.

Answer 16

16. The correct answer is C. MRC CR 07 compared short-course preoperative RT versus initial surgery with selective postoperative chemoRT for patients with a positive circumferential margin. TME was encouraged, but not required (92 % underwent TME). One thousand three hundred fifty patients were randomized. Preoperative RT consisted of 25 Gy over 5 fractions and adjuvant chemoRT was 45 Gy/25 fractions with concurrent 5-FU. With a median follow-up of 4 years, 3-year local recurrence was 4.4 % versus 10.6 % favoring the preopera- tive RT arm. Three-year disease-free survival was also improved (77.5 % vs. 71.5 %). There was no difference in overall survival. Sebag-Montefi ore D et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C0616): a multicentre, randomized trial. Lancet. 2009;373(9666):811–20.

Question 17

17. Late side effects of the short-course preoperative radiotherapy arm for rectal cancer compared to TME-alone arm as reported by the Dutch colorectal cancer group study found:

A. Stoma function was worse in the radiated arm.

B. Urinary function was worse in the radiated arm.

C. Fecal incontinence was worse in the radiated arm.

D. Satisfaction with bowel function was similar between both arms.

Answer 17

17. The correct answer is C. Late side effects from the Dutch colorectal study were reported with a median follow-up of 5.1 years. Stoma function, urinary func- tion, and hospital treatment rates did not differ signifi cantly between the treatment arms. However, irradiated patients, compared with nonirradiated patients, reported increased rates of fecal incontinence (62 % vs. 38 %, respec- tively; p < 0.001), pad wearing as a result of incontinence (56 % vs. 33 %, respectively; p < 0.001), anal blood loss (11 % vs. 3 %, respectively; p = 0.004), and mucus loss (27 % vs. 15 %, respectively; p = .005). Satisfaction with bowel function was signifi cantly lower and the impact of bowel dysfunction on daily activities was greater in irradiated patients compared with patients who under- went TME alone. Peeters et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients – a Dutch colorectal cancer group study. J Clin Oncol. 2005;23(25):6199–206.

Question 18

18. The UK ACT II trial for anal canal cancer was a randomization of:

A. RT and two different chemotherapy regimens: MMC/5-FU versus CDDP/5-FU

B. Observation after chemoRT versus maintenance CDDP/5-FU for 2 cycles

C. IMRT + MMC/5-FU versus 3D RT + MMC/5-FU

D. A and B

Answer 18

18. The correct answer is D. The ACT II trial was a 2 × 2 randomization. Nine hundred and forty patients were randomized to either arm 1 (RT 50.4 Gy/28 fractions + 5-FU 1,000 mg/m 2 days 1–4 and days 29–32 + cisplatin 60 mg/m 2 day 1 and day 29) or arm 2 (same RT and 5-FU + mitomycin 12 mg/m 2 day 1). Patients were then randomized to +/− maintenance chemo: arm 1 (cisplatin + 5-FU × 2 cycles) versus arm 2 (observation). Complete response did not differ between those receiving MMC versus cisplatin (~95 %). Comparing observa- tion after CRT versus maintenance chemotherapy, there was no difference in S. Chennupati et al. arnmayer@uni-mainz.de225 recurrence- free or overall survival, or the number of pretreatment colostomies reversed. James R et al. Randomized trial of chemoradiation using mitomycin or cisplatin, with or without maintenance cisplatin/5-FU in squamous cell carcinoma of the anus (ACT II). J Clin Oncol. 2009;27:18s. (ASCO abstract)

Question 19

19. A 66-year-old man with a T2N1 anal canal cancer is being evaluated for definitive chemotherapy and radiation. The addition of mitomycin C to 5-FU for systemic therapy with concurrent radiation has been shown to decrease:

A. Toxicity

B. Colostomy rate

C. Overall survival

D. Colostomy free survival

Answer 19

19. The correct answer is B. RTOG 87-04 randomized approximately 300 patients to treatment with (1) RT (45–50.4 Gy) and 5-FU versus RT (45–50.4 Gy) and 5-FU+mitomycin. At 4 years of follow-up, colostomy rates were lower in the MMC arm (9 % vs. 22 %), as was local failure (16 % vs. 34 %). Colostomy-free survival was increased in the MMC arm (71 % vs. 59 %). Toxicity was increased in the MMC arm (23 % vs. 7 %). Overall survival was not signifi cantly different between the two arms. Despite its increased toxicity, this trial showed that MMC cannot be eliminated without a corresponding increase in colostomy rates and local failure. Flam et al. Role of mitomycin in combination with fl uorouracil and radiotherapy, and of salvage chemoradiation in the defi nitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J Clin Oncol. 1996;14(9):2527–39

Question 20

20. Which of the following would be classified as an anal margin tumor?

A. A lesion confined to within 5 cm of the anal verge, but not including the anal verge

B. A circumferential lesion confi ned to the anal canal

C. A lesion confi ned to 1 cm proximal to the anal verge

D. A lesion at the same level as the dentate line

Answer 20

20. The correct answer is A. According to the NCCN Guidelines from 2012, the anal margin starts at the anal verge and includes the perianal skin over a 5–6 cm radius from the squamous mucocutaneous junction. Anal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 2.2012.

Question 21

21. A 71-year-old woman with an ECOG 1 performance status presents with a 1 cm well- differentiated perianal squamous cell lesion within 1 cm of the anal verge. The lesion does not come into contact with the anal verge. Inguinal exam, gynecologic exam, and CT are negative for any other sites of disease. The recommended treatment of this lesion would be:

A. Cisplatin-based chemotherapy +/− radiation

B. MMC/5-FU-based chemoradiation

C. Abdominoperineal resection

D. Local excision

Answer 21

21. The correct answer is D. This is technically an anal margin tumor. NCCN Guidelines recommend that it should be treated as if it were a skin cancer, i.e., local excision. If the lesion had come into contact with the anal verge or was unresectable, chemoRT could be considered. Anal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 2.2012

Question 22

22. A 62-year-old woman was initially diagnosed with a T3N1 rectal adenocarcinoma 7 cm from the anal verge. She received preoperative chemoRT (CI 5-FU and 50.4 Gy to tumor), followed by a low anterior resection 6 weeks later. Upon final review of the pathology, the tumor was pT2 N0. She has since recovered from this procedure and has a performance status of ECOG 1. What is the most appropriate next treatment step for this patient?

A. Close observation with CT CAP and CEA annually for 3–5 years

B. Adjuvant oxaliplatin for 6 months

C. Adjuvant 5-FU and leucovorin for 6 months

D. Adjuvant oxaliplatin for 6 months

Answer 22

22. The correct answer is C. This patient should receive adjuvant chemotherapy for 6 months with any of the following regimens: 5-FU+/−leucovorin, FOLFOX, and capecitabine +/− oxaliplatin. Rectal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 3.2012

Question 23

23. A 68-year-old woman with a history of T2 N1 rectal adenocarcinoma treated with neoadjuvant chemoradiotherapy (CI 5-FU and 50.4 Gy to the primary), LAR, and 6 months of adjuvant chemotherapy is found to have a recurrence at the anastomotic site at her 2-year follow-up. performance status ECOG is 1. Restaging studies identify this as the only site of disease. The gross area of disease is technically resectable. Which of the following is true regarding her treatment options at this time?

A. Given the prior history of radiation, the risks of more radiation would outweigh the benefits.

B. Given the prior history of radiation, the risks of surgery would outweigh the benefits.

C. The only acceptable treatment at this time other than observation is chemotherapy.

D. Repeat radiation or chemoradiation, followed by surgery, may result in long- term local control.

Answer 23

23. The correct answer is D. Several studies have shown that if appropriately man- aged, patients with a local recurrence can have good long-term control. Das et al. Hyperfractionated accelerated radiotherapy for rectal cancer in patients with prior pelvic irradiation. Int J Radiat Oncol Biol Phys. 2010;77(1):60–5. Valentini et al. Preoperative hyperfractionated chemoradiation for locally recur- rent rectal cancer in patients previously irradiated to the pelvis: a multicentric phase II study. Int J Radiat Oncol Biol Phys. 2006;64(4):1129–39.

Question 24

24. Approximately what percentage of patients with anal canal carcinoma present with rectal bleeding?

A. 75 %

B. 65 %

C. 55 %

D. 45 %

Answer 24

24. The correct answer is D. 45 % of patients with anal carcinoma present with rectal bleeding. Approximately one third present with either pain or the sensa- tion of a rectal mass. Ryan et al. Carcinoma of the anal canal. N Engl J Med. 2000;342(11):792–800

Question 25

25. A 56-year-old man with an ECOG 1 performance status has a new diagnosis of T2 N1 rectal adenocarcinoma and is found to have a liver mass on staging CT chest/abdomen/pelvis. Biopsy of this lesion is consistent with metastatic adenocarcinoma. This is the only site of distant disease found on staging studies. After evaluation by the surgery team, it is felt that the liver lesion is resectable. Which of the following is the most appropriate treatment approach?

A. This patient has metastatic disease – chemotherapy alone.

B. Resection of the liver lesion followed by neoadjuvant chemoRT to the primary followed by resection of the primary.

C. Neoadjuvant chemoRT followed by resection of the primary and the liver lesion.

D. Either B or C.

Answer 25

25. The correct answer is D. Management of patients that present with oligometa- static disease is controversial. However, given 5-year survival rates of 30–70 % following resection, there is a good argument to be made for aggressive treat- ment in patients with good performance status. The sequencing of treatment of primary and metastatic lesion is variable and is often determined by patient symptoms. Expert Panel on Radiation Oncology. American College of Radiology: Rectal Cancer – Metastatic Disease at Presentation. American College of Radiology ACR Appropriateness Criteria® 2010.

Question 26

26. A 59-year-old man presents with a rectal mass, 10 cm from the anal verge. Biopsy shows moderately differentiated adenocarcinoma. It invades through the muscularis propria on EUS, and there is one enlarged perirectal lymph node on CT. CT liver is negative for metastatic disease. He is to be treated with neoadjuvant chemotherapy and radiation. Which of the following regions does not need to be included in the radiation treatment field?

A. Internal iliac lymph nodes

B. External iliac lymph nodes

C. Presacral iliac lymph nodes

D. Perirectal lymph nodes

Answer 26

26. The correct answer is B. The patient has a T3N1 rectal adenocarcinoma. The external iliac lymph nodes are not likely to be involved for this particular case. In T3 rectal carcinoma, the anterior border of the lateral fi elds is behind the pubic symphysis. For patients with T4 tumors invading anterior structures, the anterior block is often brought forward to cover a portion of the external iliac lymph nodes. Rectal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 3.2012

Question 27

27. A 68-year-old male with a newly diagnosed 3 cm anal cancer and a biopsy proven left inguinal lymph node presents to clinic. An HIV test returns positive and CD4 + count returns 250/mm 3 . The most appropriate treatment regimen for this patient is:

A. Concurrent chemotherapy and radiation with MMC and 5-FU

B. Treatment with chemotherapy only using a 5-FU-based regimen

C. Radiation alone

D. Optimization of CD4 + count to greater than 400/mm 3 prior to starting chemotherapy and radiation with MMC and 5-FU

Answer 27

27. The correct answer is A. Patients with HIV/AIDS have been reported to be at an increased risk of developing anal carcinoma. Numerous studies have found that patients with anal carcinoma as the fi rst manifestation of HIV may be treated with the same regimen as non-HIV patients. Several retrospective series have found no difference with respect to treatment or 2-year survival when comparing HIV patients versus non-HIV patients. Chiao et al. Human immunodefi ciency virus-associated squamous cell cancer of the anus: epidemiology and outcomes in the highly active antiretroviral therapy era. J Clin Oncol. 2008;26(3):474–9. Hoffman et al. The signifi cance of pretreatment CD4 count on the outcome and treatment tolerance of HIV-positive patients with anal cancer. Int J Radiat Oncol Biol Phys. 1999;44(1):127–31. Fraunholz et al. Concurrent chemoradiotherapy with 5-fl uorouracil and mitomycin C for invasive anal carcinoma in human immunodefi ciency virus-positive patients receiving highly active antiretroviral therapy. Int J Radiat Oncol Biol Phys. 2010;76(5):1425–32.

Question 28

28. What percentage of clinically positive lymph nodes in patients with anal canal cancer are pathologically positive on biopsy?

A. 100 %

B. 75 %

C. 50 %

D. 25 %

Answer 28

28. The correct answer is C. This stresses the importance of sampling any clinically positive lymph nodes to accurately stage patients. This is increasingly impor- tant as many treatment protocols stratify treatment of patients with anal cancer based on N stage. Anal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 2.2012

Question 29

29. 80 % of colon cancer has the following mutation:

A. 1p19q

B. 4p

C. 9q

D. 17p, 18q

Answer 29

29. The correct answer is D. Colon cancer has a major genetic component. Approximately 80 % of these cancers contain 17p (p53) or 18q (DCC – deleted colon cancer) mutation. Lurje et al. Molecular prognostic markers in locally advanced colon cancer. Clin Colorectal Cancer. 2007;6(10):683–90.

Question 30

30. Patients with familial adenomatous polyposis contain a mutation of which tumor suppressor gene?

A. p53

B. APC

C. FAP

D. VHL

Answer 30

30. The correct answer is B. Patients with FAP contain a mutation of the APC tumor suppressor gene – the most common of which is 5q21. O’Sullivan et al. S. Chennupati et al. arnmayer@uni-mainz.de227 Familial adenomatous polyposis: from bedside to benchside. Am J Clin Pathol. 1998;109(5):521–6.

Question 31

31. What is the risk of developing colorectal cancer for a patient who is a carrier of a 5q21 mutation?

A. 55 %

B. 70 %

C. 85 %

D. 100 %

Answer 31

31. The correct answer is D. Familial adenomatous polyposis (5q21 mutation) has an autosomal dominant inheritance. There is a 100 % risk of developing colorectal cancer for these patients. Over 95 % of patients have cancer by age 45 if left untreated. Surveillance is recommended to start in the early teens per the American Cancer Society. Galiatsatos P, Foulkes WD. Familial adenoma- tous polyposis. Am J Gastroenterol. 2006;101(2):385–98.

Question 32

32. All of the following are cancers that can be seen in those with Lynch II syndrome, except:

A. Endometrial cancer

B. Breast cancer

C. Gastric cancer

D. Ovarian cancer

Answer 32

32. The correct answer is B. Lynch II syndrome is a variant of hereditary nonpol- yposis colorectal cancer (HNPCC), due to a DNA mismatch repair defect. It is autosomal dominantly inherited and tends to occur in younger individuals (mean age of 46 years). In addition to colon cancer, other associated cancers include endometrial, ovarian, gastric, and upper urinary tract cancers. Lynch HT et al. Hereditary factors in cancer. Study of two large midwestern kindreds. Arch Intern Med. 1966;117(2):206–12

Question 33

33. A 64-year-old woman with a performance status of ECOG 1 presents with a small rectal mass, approximately 7 cm from the anal verge. Biopsy reveals adenocarcinoma and EUS finds that the lesion is limited to the submucosa. She undergoes local excision. Which of the following pathologic findings would require consideration of adjuvant therapy?

A. Moderately differentiated adenocarcinoma is found on final pathology.

B. The margins are negative by 0.5 cm.

C. The lesion is found to be 2.5 cm in greatest dimension.

D. The specimen invades through the muscularis propria.

Answer 33

33. The correct answer is D. RTOG 89-02 was a phase II clinical trial in which patients with T1-3 rectal tumors were assigned transanal or trans-sacral exci- sions followed by observation or chemoRT. Local failure was 0 % for patients with T1 tumors versus 20 % for patients with T2 tumors. The current NCCN Guidelines recommend transanal excision alone only for T1N0 tumors that are less than 3 cm in size, mobile/nonfi xed, negative surgical margins (>3 mm) with no PNI or LVSI, and not poorly differentiated. Russell et al. Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of Radiation Therapy Oncology Group protocol 89-02. Int J Radiat Oncol Biol Phys. 2000;46(2):313–22.

Question 34

34. What colon cancer screening program is appropriate for a 48-year-old male with no personal or family history of colorectal cancer or polyps and no history of infl ammatory bowel disease (ulcerative colitis or Crohn’s disease)?

A. Flexible sigmoidoscopy every 10 years starting at age 50

B. Double-contrast barium enema every 5 years starting at age 50

C. Colonoscopy every 10 years starting at age 60

D. CT colonography every 10 years starting at age 50

Answer 34

34. The correct answer is B. According to the American Cancer Society, patients with average risk (i.e., no personal or family history, no infl ammatory bowel disease) should have screening starting age 50 with any of the following: fl exi- ble sigmoidoscopy every 5 years, colonoscopy every 10 years, double- contrast barium enema every 5 years, or CT colonography (virtual colonoscopy) every 5 years. American Cancer Society. American Cancer Society recommendations for colorectal early detection. Last revised 6/15/2012

Question 35

35. The most common site of local recurrence for patients with rectal cancer is:

A. Presacral space

B. Perineum

C. Posterior wall of the bladder

D. Common iliac lymph nodes

Answer 35

35. The correct answer is A. Multiple studies have reported the most common site of local recurrence is the presacral space. In patients from the Dutch TME trial, presacral recurrences were most common in both the RT+TME and the TME- alone arms. Local recurrences in this region can be extremely symptomatic and diffi cult to treat. This is the reason that the posterior border in both the initial and boost fi elds should extend just beyond the sacrum. Kusters et al. Patterns of local recurrence in rectal cancer a study of the Dutch TME trial. Eur J Surg Oncol. 2010;36(5):470–76

Question 36

36. What is the most common presenting symptom for patients with rectal cancer?

A. Weight loss

B. Rectal bleeding

C. Urinary symptoms

D. Sciatic pain

Answer 36

36. The correct answer is B. The most common presenting symptom for patients with rectal cancer is frank rectal bleeding. Minsky BD, Welton ML, Venook AP. Cancer of the rectum. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips textbook of radiation oncology. 3rd ed. Philadelphia: Elsevier Saunders; 2010. p. 851–69.

Question 37

37. Which of the following parts of the large bowel is retroperitoneal?

A. Transverse colon

B. Sigmoid colon

C. Appendix and cecum

D. Ascending colon

Answer 37

37. The correct answer is D. The ascending colon and descending colon are retro- peritoneal. Minsky BD, Welton ML, Venook AP. Cancer of the rectum. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips textbook of radia- tion oncology. 3rd ed. Philadelphia: Elsevier Saunders; 2010. p. 851–69

Question 38

38. Hereditary nonpolyposis colorectal cancer (HNPCC) is characterized by which of the following?

A. It is characterized by an autosomal recessive inheritance.

B. It results from a defect in p53.

C. It leads to malignancy more common in the proximal/ascending colon.

D. HNPCC-associated cancers present at an average age of 25.

Answer 38

38. The correct answer is C. Almost two thirds of these cancers occur in the proxi- mal colon. HNPCC is an autosomal dominant trait characterized by a defect in mismatch repair. The average age of colorectal cancer diagnosis is around 45. These patients have an 80 % chance of developing a colorectal cancer. Minsky BD, Welton ML, Pineda CE, Venook AP. Cancer of the colon. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips textbook of radiation oncol- ogy. 3rd ed. Philadelphia: Elsevier Saunders; 2010. p. 842–50.

Question 39

39. For patients with metastatic rectal adenocarcinoma, mutations in codons 12 and 13 of the coding region of the KRAS gene predict:

A. A lack of response to therapy with antibodies targeting the epidermal growth factor receptor

B. An increased response to therapy with antibodies targeting the epidermal growth factor receptor

C. A lack of response to therapy with antibodies targeting the vascular endothelial growth factor receptor

D. An increased response to therapy with antibodies targeting the vascular endothelial growth factor receptor

Answer 39

39. The correct answer is A. Antibodies targeting the epidermal growth factor receptor have been shown to be more effective in patients with an intact (i.e., wild type) KRAS gene. Cunningham et al. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med. 2004;351(4):337–45. Amado et al. Wild-type KRAS is required for panitumumab effi cacy in patients with metastatic colorectal cancer. Clin Oncol. 2008;26(10):1626–34.

Question 40

40. A 51-year-old woman with a history of rectal adenocarcinoma treated with neoadjuvant chemotherapy, surgery, and adjuvant chemotherapy is found to have metastatic disease 6 months after completing therapy. KRAS and BRAF V600E mutation testing are requested. Which of the following is true concerning BRAF testing?

A. A new specimen is required, as BRAF testing cannot be performed on fixed tissues.

B. Allele-specifi c PCR is an acceptable method of detecting the BRAF V600E mutation.

C. Patients with the BRAF V600E mutation have a better prognosis.

D. Tissue specimens cannot be paraffin embedded as it degrades the DNA.

Answer 40

40. The correct answer is B. Allele-specifi c PCR is an acceptable method of detect- ing this mutation. Other alternatives include PCR amplifi cation and direct DNA sequence analysis. This can be done on formalin-fi xed, paraffi n-embedded tis- sues. Patients with a BRAF V600E mutation have a poorer prognosis. Bokemeyer et al. Cetuximab with chemotherapy (CT) as fi rst-line treatment for metastatic colorectal cancer (mCRC): analysis of the CRYSTAL and OPUS studies accord- ing to KRAS and BRAF mutation status. J Clin Oncol. 2010;28(Suppl):3506

Question 41

41. Which of the following is true regarding the accuracy of endoscopic ultrasound (EUS), MRI, and CT in preoperative staging of rectal cancer according to NCCN Guidelines?

A. EUS and MRI have similarly high sensitivities for evaluating the depth of tumor penetration into the muscularis propria (~94 %).

B. CT is an acceptable substation for EUS for determining T stage.

C. EUS has >90 % sensitivity for detecting involved lymph nodes.

D. The high degree of operator dependence of EUS makes it an unreliable option for determining T stage.

Answer 41

41. The correct answer is A. MRI and EUS are similarly sensitive for evaluating depth of tumor penetration into the muscularis propria (~94 %). CT is not con- sidered to be an optimal method for staging the extent of tumor penetration. A meta-analysis reported the sensitivity of EUS for detecting lymph node involvement to be approximately 67 %. While the degree of operator dependence of EUS is a disadvantage, it is still the most commonly used staging method for determining depth of invasion. Bipat et al. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging – a meta-analysis. Radiology. 2004;232:773–83. Rectal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 3.2012

Question 42

42. Vitamin D may contribute to colorectal cancer incidence in which way?

A. Deficiency may contribute to increased incidence of colorectal cancer.

B. Deficiency may contribute to decreased mortality in patients with stage III and IV disease.

C. Supplementation has been shown to improve outcomes in patients with early stage disease.

D. Excess vitamin D has been shown to contribute to incidence of colorectal cancer.

Answer 42

42. The correct answer is A. Prospective studies have suggested that vitamin D defi ciency may increase the incidence of colorectal cancer. Two prospective trials have shown that colorectal cancer patients with low vitamin D levels had increased mortality, especially those with stage III–IV disease. There is still no clear evidence to suggest that supplementation would improve outcomes. Ng K et al. Circulating 25-hydroxyvitamin d levels and survival in patients with colorectal cancer. J Clin Oncol. 2008;26:2984–91. Lappe JM et al. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007;85:1586–91.

Question 43

43. All are true regarding the GITSG 7175 trial to determine optimal adjuvant therapy for rectal cancer, except:

A. No overall survival benefi t has been seen.

B. Time to recurrence was prolonged with combined adjuvant therapy.

C. The control arm was observed after surgery.

D. Chemotherapy consisted of 5-FU and MeCCNU.

Answer 43

43. The correct answer is A. GITSG 7175 was a 4-arm study to determine the opti- mal adjuvant therapy. Two hundred twenty-seven patients with locally advanced rectal cancer were randomized to one of four arms: (1) surgery alone, (2) sur- gery + radiation alone (40 or 48 Gy), (3) surgery + chemotherapy alone, and (4) surgery + chemoradiation. Chemotherapy consisted of 5-FU and MeCCNU. The initial report in 1985 with a median follow-up of 80 months showed the lowest recurrence rate in those receiving adjuvant chemoRT (33 %) and the highest in those receiving no adjuvant therapy (55 %). Time to tumor recur- rence was also the longest in the chemoRT arm versus observation ( p < 0.009). In the initial report, there was no overall survival benefi t. The latest update in 1988 did show an overall survival benefi t for chemoRT versus observation (45 % vs. 27 %, p = 0.01), in addition to prolonged time to recurrence. Prolongation of the disease-free interval in surgically treated rectal carcinoma. N Engl J Med. 1985;312:1265–472. Thomas PR et al. Adjuvant postoperative radiotherapy and chemotherapy in rectal carcinoma: a review of the Gastrointestinal Tumor Study Group experience. Radiother Oncol. 1988;13(4): 245–52.

Question 44

44. Which statement is true regarding the MOSAIC trial of adjuvant chemotherapy for resected colon cancer?

A. 5-FU alone was compared to FOLFOX.

B. Disease-free survival improved with the addition of oxaliplatin.

C. Only stage II patients experienced an overall survival benefi t with the addition of oxaliplatin.

D. Both stage II and III patients experienced an overall survival benefit with the addition of oxaliplatin.

Answer 44

44. The correct answer is B. The MOSAIC trial randomized 2,246 patients with stage II/II colon cancer s/p curative resection to receive either bolus + continu- ous infusion 5-FU + leucovorin or bolus + continuous infusion 5-FU + leucovo- rin + oxaliplatin (FOLFOX). Final results of the study reported improved in 6-year overall survival in stage III patients (72.9 % vs. 68.7 %, p = 0.023) and improved 5-year disease-free survival (73.3 % vs. 67.4 %, p = 0.003) in all patients with the addition of oxaliplatin. No overall survival benefi t was seen in stage II patients. André T et al. Improved overall survival with oxaliplatin, fl uo- rouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the MOSAIC trial. J Clin Oncol. 2009;27(19):3109–16.

Question 45

45. By anatomical landmarks, which of the following structures marks the superior border of the anal canal?

A. Levator ani

B. Anal verge

C. Upper border of the anal sphincter and puborectalis muscles of the anorectal ring

D. Lowermost edge of the sphincter muscles

Answer 45

45. The correct answer is C. The superior border is defi ned as the upper border of the anal sphincter and puborectalis muscles of the anorectal ring. This func- tional defi nition is used primarily in the radical surgical treatment of anal can- cer. Cummings BJ, Ajani JA, Swallow CJ. Cancer of the anal region. In: DeVita Jr VT, Lawrence TS, Rosenberg SA, et al., editors. Cancer: principles and prac- tice of oncology. 8th ed. Philadelphia: Lippincott, Williams & Wilkins; 2008.

Question 46

46. Which of the following pathologic features is useful in differentiating anal margin tumors from anal canal tumors?

A. The lack of skin appendages (hair follicles or sweat glands) indicates an anal margin tumor.

B. Non-keratinizing, large-cell-type squamous cell carcinomas are more likely to be anal margin tumors.

C. Well-differentiated tumors are more likely to be anal margin tumors.

D. There are no clear pathologic differences.

Answer 46

46. The correct answer is C. Squamous cell carcinomas of the anal margin are more likely to be well differentiated and contain skin appendages (hair follicles or sweat glands). Keratinizing large-cell-type squamous cell carcinomas are more likely to be anal margin tumors. It is not always possible to distinguish between anal margin and anal canal tumors since these lesions can involve both areas. Cummings BJ, Ajani JA, Swallow CJ. Cancer of the anal region. In: DeVita Jr VT, Lawrence TS, Rosenberg SA, et al., editors. Cancer: principles n practice of oncology. 8th ed. Philadelphia: Lippincott, Williams & Wilkins; 2008.

Question 47

47. A 58-year-old HIV-negative man presents with a new diagnosis of T1Nx squamous cell carcinoma of the anal canal found on digital rectal exam. The lesion is located at the level of the anal verge, distal to the dentate line. The location of this primary, as opposed to a tumor above the dentate line, makes lymph node metastases to which site more likely?

A. Internal iliac lymph nodes

B. Perirectal lymph nodes

C. Paravertebral lymph nodes

D. Superficial inguinal lymph nodes

Answer 47

47. The correct answer is D. A distal anal cancer has a higher incidence of metas- tasizing to the inguinal lymph nodes, compared to a more proximal cancer. Drainage of lesions proximal to the dentate line is towards the anorectal, peri- rectal, paravertebral, and internal iliac lymph nodes. It is important to note that the drainage of each site is not isolated and a proper staging work-up is always warranted. Rectal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 3.2012.

Question 48

48. The phase III, UK ACT II trial was one of the largest trials for patients with anal cancer. Patients with newly diagnosed anal cancer were randomized to either

5-FU/MMC or 5-FU/cisplatin combined with radiation to a dose of 50.4 Gy. Following treatment, patients in each arm were randomized to receive 2 cycles of maintenance chemotherapy (5-FU/cisplatin) versus observation. Results were presented after a median follow-up of 3 years. Which of the following is a result from the trial?

A. Recurrence-free survival was not impacted by maintenance therapy compared to observation.

B. Colostomy-free survival was improved for patients in 5-FU/cisplatin arm compared to the 5-FU/MMC arm.

C. Complete response rate was improved for patients receiving MMC.

D. Overall survival was improved for patients receiving MMC.

Answer 48

48. The correct answer is A. The ACT II trial was a 2 × 2 randomization. Nine hun- dred and forty patients were randomized to either arm 1 (RT 50.4 Gy/28 fractions + 5-FU 1,000 mg/m 2 days 1–4 and days 29–32 + cisplatin 60 mg/m 2 day 1 and day 29) or arm 2 (same RT and 5-FU + mitomycin 12 mg/m 2 day 1). Patients were then randomized to +/− maintenance chemo: arm 1 (cisplatin + 5-FU × 2 cycles) versus arm 2 (observation). At a median follow-up of 3 years, complete response did not differ between those receiving MMC versus cisplatin (~95 %). Comparing observation after CRT versus maintenance chemotherapy, there was no difference in recurrence-free or overall survival, or the number of pretreatment colostomies reversed. Longer follow-up of this trial is still pending. James R et al. Randomized trial of chemoradiation using mitomycin or cispla- tin, with or without maintenance cisplatin/5-FU in squamous cell carcinoma of the anus (ACT II). J Clin Oncol. 2009;27:18s. (ASCO abstract).

Question 49

49. A 75-year-old man with a history of a T2N1 anal canal SCCA treated with concurrent chemoRT 1 year ago presents for follow-up. Which of the following should be performed as routine follow-up?

A. PET-CT

B. Biopsy of the treatment site

C. Digital rectal exam/anoscopy

D. MRI pelvis

Answer 49

49. The correct answer is C. Digital rectal exam/anoscopy is recommended every 3–6 months following treatment. Exam should also include inguinal lymph node palpation. Annual CT of the chest, abdomen, and pelvis is recommended for 3 years in patients with initially locally advanced disease (T3/T4) tumors or LN + tumors. Anal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 2.2012.

Question 50

50. A 65-year-old woman recently completed chemoRT for treatment of a T1 N2 anal carcinoma. Serial examinations after completion of treatment noted persistent disease. At the 3-month follow-up, the primary lesion was felt to be increasing in size. Which of the following is the most appropriate next step in management?

A. Referral for salvage surgery

B. Check CEA level

C. Repeat examination in 4 weeks

D. Biopsy of the lesion

Answer 50

50. The correct answer is D. Following treatment, patients should be monitored closely with repeat DREs. They should be classifi ed according to whether they have a complete remission, persistent disease, or progressive disease. At sign of progression, biopsy and restaging CT or PET should be performed. If the biopsy is positive, they should be evaluated for radical salvage surgery with an APR. Anal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 2.2012

Question 51

51. When determining if a liver metastasis in a patient with colorectal cancer is resectable, which of the following is the most important criteria to determine resectability?

A. Tumor size

B. Ability to achieve at least an R1 resection while maintaining adequate liver reserve

C. Ability to achieve an R0 resection while maintaining adequate liver reserve

D. Ability to resect the lesion while minimizing tumor spillage into the peritoneum

Answer 51

51. The correct answer is C. The most important criterion in determining resect- ability is the likelihood of achieving a complete (R0) resection while maintain- ing adequate liver reserve. Incomplete resection and debulking have not been shown to be benefi cial unless the lesion is symptomatic. Yoo et al. Liver resec- tion for metastatic colorectal cancer in the age of neoadjuvant chemotherapy and bevacizumab. Clin Clin Colorectal Cancer. 2006;6(3):202–7.

Question 52

52. Excluding hemorrhage, what is the most common fatal adverse event observed with the addition of bevacizumab to chemotherapy?

A. Venous thromboembolism

B. Gastrointestinal tract perforation

C. Aneurysm

D. Neutropenia

Answer 52

52. The correct answer is D. Based on a recent meta-analysis of randomized con- trolled trials to assess the role of bevacizumab in treatment-related mortality, the most common causes of fatal adverse events were hemorrhage (23.5 %), neutropenia (12.2 %), and gastrointestinal tract perforation (7.1 %). Ranpura et al. Treatment-related mortality with bevacizumab in cancer patients – a meta- analysis. JAMA. 2011;305(5):487–94.

Question 53

53. A 61-year-old man has recently completed defi nitive treatment for his T3 N1 rectal adenocarcinoma (neoadjuvant chemoRT, surgery, adjuvant chemotherapy). The first posttreatment colonoscopy should be scheduled at what time interval?

A. 1 year

B. 2 years

C. 5 years

D. 10 years

Answer 53

53. The correct answer is A. NCCN Guidelines recommend the fi rst colonoscopy at approximately 1 year following resection. If no preoperative colonoscopy was done due to an obstructive lesion, the fi rst colonoscopy can be done at 3–6 months. Proctoscopy should be considered every 6 months for 5 years to evaluate for local recurrence at the rectal anastomosis in patients that under- went a LAR. Rectal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Version 3.2012.

Question 54

54. Excluding cutaneous cancers, rectal cancer is the ___ most common cancer in the United States.

A. First

B. Second

C. Third

D. Fourth

Answer 54

54. The correct answer is C. Rectal cancer is the third most common cancer in the United States. In 2012, 40,290 cases of rectal cancer are expected to occur, though the incidence of colorectal cancer has been decreasing, presumably due to increases in the use of colorectal cancer screening tests. American Cancer Society. Cancer facts and fi gures. 2012. http://www.cancer.org/research/cancer- factsfi gures/cancer-facts-fi gures-2012

Question 55

55. A 51-year-old man is found to have a pedunculated polyp on routine colonoscopy. The site of the polyp was marked during the colonoscopy. Pathology revealed a single pedunculated polyp with grade 2 invasive cancer that was completely removed with no evidence of angiolymphatic invasion. What is the appropriate next step?

A. Proceed on to LAR followed by adjuvant chemotherapy and radiation.

B. Repeat colonoscopy in 3 years.

C. Proceed to WLE of the marked region.

D. Proceed with 6 months of adjuvant chemotherapy.

Answer 55

55. The correct answer is B. According to the American Cancer Society guidelines, this patient should have a repeat colonoscopy in 3 years.

Question 56

56. A 62-year-old woman is found to have a rectal mass measuring 4 cm. The pathology returns as moderately differentiated adenocarcinoma. On endoscopic ultrasound, the mass is found to invade through the muscularis propria into the perirectal fat. There are two enlarged regional lymph nodes. The remainder of the staging work-up is negative. What is the correct AJCC 7th edition TNM stage?

A. yT3 N2a M0

B. uT2 N2a M0

C. uT3 N1a M0

D. uT3 N1b M0

Answer 56

56. The correct answer is D. The correct 7th edition AJCC stage is uT3N1bM0. “u” denotes staging of the primary was done with EUS. “y” denotes pathologic review after surgical resection. N1b denotes 2–3 involved lymph nodes; N1a denotes 1 involved lymph node. Edge SB, Byrd DR, Compton CC, et al., edi- tors. Colon and rectum. AJCC cancer staging handbook. 7th ed. New York: Springer; 2010.

Question 57

57. Which of the following is the standard chemotherapeutic option for patients with metastatic anal carcinoma?

A. There is no standard; chemotherapy should be individualized.

B. Bevacizumab

C. Cetuximab

D. Taxotere

Answer 57

57. The correct answer is A. There is no clear consensus on the most appropriate chemotherapy in this setting. Treatment should be individualized and is often comprised of cisplatin-based chemotherapy. Enrollment on a clinical trial could also be considered. Ajani et al. Combination of cisplatin plus fl uoropyrimidine chemotherapy effective against liver metastases from carcinoma of the anal canal. Am J Med. 1989;87(2):221–4. Cummings et al. Metastatic anal cancer: the search for cure. Onkologie. 2006;29(1–2):5–6.