Patient Cases

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LP is a 42 yo F w chronic phase CML, started on bosutinib 400 mg PO daily. After 12 months of therapy, she has not achieved a complete cytogenetic response. Drug interactions and non-adherence with therapy have been ruled out. LP's therapy is changed from bosutinib to dasatinib. Which of the following counseling points regarding any TKI therapy for CML would be important to stress to LP during your discussion with her? A. Food does not impact the effectiveness of TKIs. B. Adherence with TKI therapy is directly associated with outcome. C. TKIs should be taken once daily to maintain serum steady state concentration. D. TKIs will be discontinued if MMR is sustained for 2 years.

AG is a 50-year-old gentleman with a new diagnosis of locally advanced squamous carcinoma of the tonsil. He has used chewing tobacco since age 12, and only has occasional alcohol use. His p16 IHC is negative indicating negative HPV status. Staging scans revealed no distant disease, but multiple positive lymph nodes (cN2), so he underwent resection of the tumor. Pathology after surgery showed positive margins. Which of the following is most appropriate for this patient at this time? A) Concurrent radiation and weekly cisplatin B) Concurrent radiation and every 3 week cisplatin C) Concurrent radiation with weekly cetuximab D) Docetaxel/fluorouracil/cisplatin then re-resection

Answer B. Since AG had positive margins after surgery, re-resection is an option, however not with induction therapy. Concurrent cetuximab is a category 2B recommendation for positive margins, and is not preferred over either re-resection or concurrent chemoradiation. There are several different regimens for chemoradiation exist but cisplatin 100 mg/m2 every 3 weeks (answer b) for 2-3 doses is the preferred chemotherapy combination with radiation. Weekly cisplatin is a category 2B recommendation.

HF is a 60-year-old healthy female with minimal comorbidities including hyperlipidemia and hyperthyroidism. She has a newly diagnosed Stage IIIB (T4, N2, M0) left breast cancer that is ER 70%, PR 0%, and HER2 IHC 3+. She would prefer a lumpectomy and radiation; therefore, she must undergo neoadjuvant chemotherapy with the hope of decreasing the size of the primary tumor to allow for adequate surgical resection. What neoadjuvant regimen would be most appropriate? A. AC + trastuzumab x 4 cycles B. Docetaxel + trastuzumab + pertuzumab x 6 cycles C. TCH + pertuzumab x 6 cycles D. AC x 4 cycles → paclitaxel weekly x 12

Answer C is correct. It is preferred that HF receives a neoadjuvant chemotherapy regimen with or without pertuzumab. Any regimen listed in table "Selected Neoadjuvant/Adjuvant Therapy for HER2-positive Breast Cancer" would be appropriate according to NCCN Guidelines®. Based on the results of the TRYPHAENA study, HF will receive docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) x 6 cycles. Answer A is incorrect because trastuzumab should not be given concurrently with an anthracycline-containing regimen due to the increased risk for cardiotoxicity. Answer B is incorrect because docetaxel + trastuzumab + pertuzumab is recommended for metastatic breast cancer not as neoadjuvant therapy. Answer D is incorrect because HF should receive a neoadjuvant regimen that contains HER2-directed therapy.

KB is a 72-year-old woman with relapsed diffuse large B-cell lymphoma. She achieved a complete response after 3 cycles of R-ICE (rituximab, ifosfamide, carboplatin, etoposide) for her relapsed disease. Question #1: What is the most appropriate therapy for KB at this time? A. Carmustine, etoposide, cytarabine, melphalan + rituximab (BEAM -R) myeloablative conditioning followed by autologous HSCT B. Busulfan and fludarabine reduced intensity conditioning followed by autologous HSCT C. Busulfan and fludarabine myeloablative conditioning followed by an allogeneic HSCT D. Anti-CD19 CAR T-cell therapy

Answer: A. Carmustine, etoposide, cytarabine, melphalan + rituximab (BEAM -R) myeloablative conditioning followed by autologous HSCT. The recommended treatment for patients with a complete response in first relapse is high-dose/myeloablative chemotherapy with autologous HSCT. BEAM-R is a standard myeloablative regimen utilized for B-cell lymphoma. A reduced intensity regimen of busulfan and fludarabine followed by autologous HSCT would not be recommended for this patient, as high dose/myeloablative therapy is indicated for this indication. Myeloablative allogeneic HSCT should not be offered to a patient with DLBCL before an autologous HSCT due to increased toxicities. The NCCN guidelines only recommend allogeneic transplant for select cases such as mobilization failure or residual bone marrow involvement of disease. Anti-CD19 CAR T-cell therapy is currently indicated and FDA-approved in patients with DLBCL who have relapsed/refractory disease after 2 or more lines of therapy.

KB is a 72-year-old woman with relapsed DLBCL. She received high dose BEAM-R conditioning followed by autologous HSCT. She is now 1 year post transplant. She has no laboratory abnormalities on routine follow-up labs and no signs or symptoms of organ dysfunction. Question #7: Which of the following screenings should KB receive for long-term complications at this time? A. Echocardiogram B. Bone mineral density testing C. Renal ultrasound D. Pulmonary function tests

Answer: B. Bone mineral density testing. Based on the 2012 guidelines for recommended screening and preventative practices for long-term survivors after HSCT353, all women should receive bone mineral density testing at 1 year post-transplant. Echocardiogram, renal ultrasound, and pulmonary function tests would not be routine screening and would only be done if indicated based on clinical presentation/assessment.

KB is a 72-year-old woman with relapsed diffuse large B-cell lymphoma. She is planning to receive high dose carmustine, etoposide, cytarabine, melphalan + rituximab (BEAM -R) conditioning followed by an autologous HSCT. Question #3: Which of the following is the most appropriate to recommend that KB receive to prevent mucositis? A. Sargramostim mouth rinses B. Doxepin mouth rinses C. Ice chips D. Palifermin

Answer: C. Ice chips. Sargramostim mouthwashes have been evaluated for prevention of mucositis and are not recommended by the MASCC/ISOO guidelines. Doxepin mouth rinses are used for treatment of oral mucositis pain, not for prevention of mucositis. Palifermin has not demonstrated benefit in patients receiving melphalan conditioning regimens. Ice chips are suggested by the MASCC/ISOO guidelines as they have been shown to minimize mucositis related to melphalan.

SV is a 65-year-old male with AML in first complete remission who underwent a haploidentical allogeneic HSCT. He received tacrolimus, mycophenolate and post-transplant cyclophosphamide to prevent GVHD. He presents on day + 35 with a maculopapular skin rash on 45% of his body and had 1200 mL of diarrhea in the past 24 hours. He is diagnosed with overall grade III acute GVHD. Question #5: Which of the following is the most appropriate GVHD treatment for SV at this time? A. Ruxolitinib 5 mg twice daily B. Prednisone 0.5 mg/kg/day + beclomethasone C. Methylprednisolone 2 mg/kg/day D. Methylprednisolone 2 mg/kg/day + infliximab

Answer: C. Methylprednisolone 2 mg/kg/day. The most appropriate initial therapy per the NCCN© and ASTCT guidelines is methylprednisolone 2 mg/kg/day12,184. Ruxolitinib is approved for steroid-refractory acute graft-versus-host disease, and should not be utilized as a single-agent as first line. Beclomethasone + prednisone may be appropriate for patients with upper gastrointestinal GVHD alone, but is not recommended therapy for lower gastrointestinal GVHD. Infliximab added to methylprednisolone will increase toxicity but not efficacy

SV is a 65-year-old male with AML in first complete remission and is planning to undergo a haploidentical allogeneic HSCT. He is scheduled to receive nonmyeloablative fludarabine, cyclophosphamide and total body irradiation as conditioning prior to HSCT. Question #2: Which of the following should SV receive to prevent toxicity from his conditioning regimen? A. Continuous bladder irrigation B. Phenytoin C. Ursodiol D. Twice daily skin cleaning

Answer: C. Ursodiol. The patient should receive ursodiol for prevention of veno-occlusive disease. Continuous bladder irrigation is not recommended by the American Society of Clinical Oncology: Use of Chemotherapy and Radiation Therapy Protectants Guidelines80 for prevention of hemorrhagic cystitis with cyclophosphamide. Phenytoin or other antiepileptic medication is required with busulfan therapy. Twice daily skin cleaning is recommended for thiotepa use.

SV is a 65-year-old male with AML in first complete remission who underwent a haploidentical allogeneic HSCT. He was tapered off all immunosuppression by day +190. He subsequently developed moderate chronic GVHD involving his skin and oral mucosa and is now starting prednisone 1 mg/kg/day at day +240. Question #6: Which of the following is the most appropriate infection prophylaxis for SV at this time? A. Acyclovir, pentamidine, posaconazole, and penicillin B. Valganciclovir, pentamidine, fluconazole, and penicillin C. Valacyclovir, sulfamethoxazole/trimethoprim, voriconazole, and penicillin D. Acyclovir, sulfamethoxazole/trimethoprim, posaconazole, and penicillin

Answer: D. Acyclovir, sulfamethoxazole/trimethoprim, posaconazole, and penicillin Acyclovir to prevent HSV/VZV as he remains on immunosuppressive therapy; valacyclovir would be an acceptable alternative, although it has a lower grade of recommendation. Intravenous ganciclovir could be used for prophylaxis, but valganciclovir should not be used a prophylaxis given it is not more effective than as preemptive therapy and is more toxic as prophylaxis. Sulfamethoxazole/Trimethoprim is recommended to prevent PJP; pentamidine could be considered but is considered less effective and has a narrower spectrum of activity. Posaconazole has been shown to be superior to fluconazole in the setting of GVHD requiring corticosteroids. Voriconazole has not been found to be superior to fluconazole in all patients post allogeneic HSCT. Posaconazole is also the preferred option due to an improved toxicity profile. Penicillin is recommended to prevent Streptococcus pneumoniae for allogeneic recipients with chronic GVHD as long as active chronic GVHD treatment is administered and is generally started after engraftment when broad spectrum agents are discontinued.

SV is a 65-year-old male with AML in first complete remission and is planning to undergo a haploidentical allogeneic HSCT. Question #4: What is the most appropriate graft-versus-host disease prophylaxis regimen for SV? A. Cyclosporine + methotrexate B. Post-transplant cyclophosphamide C. Tacrolimus + mycophenolate + anti-thymocyte globulin D. Tacrolimus + mycophenolate + post-transplant cyclophosphamide

Answer: D. Tacrolimus + mycophenolate + post-transplant cyclophosphamide. Post-transplant cyclophosphamide in combination with tacrolimus and mycophenolate is the most appropriate standard of care combination immunosuppression for a haploidentical transplant based on multiple clinical trials demonstrating acceptable rates of acute and chronic graft-versus-host disease in this population.

LL. is a 51-year-old man who was referred to urology after presenting to his PCP with several months of intermittent hematuria. His past medical history is significant only for hypertension (controlled with amlodipine). Workup revealed a 10cm tumor of the left kidney (clear cell histology) with regional lymph node involvement (Stage III). Following radical nephrectomy, LL chooses not to pursue adjuvant sunitinib. At his 2-year follow up, he is noted to have lymphadenopathy on his abdominal CT. A chest CT shows a 2 cm lung lesion. Biopsy of the lung lesion was consistent with metastatic clear cell renal cell carcinoma. His BP is 124/72 (on amlodipine). Pertinent labs: SCr 1 mg/dl, Ca 9.3 mg/dl, Alb 4.2 g/dl, WBC 7.0 x 109/L, ANC 4.0 x 109/L, Hgb 14.1 g/dL, Platelets 250K, Karnofsky performance score is 90%. Which of the following is the most appropriate treatment option for LL? A) Ipilimumab + nivolumab B) Cabozantinib C) Lenvatinib plus everolimus D) Pazopanib

Based on the time to recurrence being > 1 year and the patient's Hgb, SCr, ANC and platelets being in the normal range with the Karnofsky score being > 80%, the patient is classified as having favorable risk disease. The correct choice is D. Pazopanib is the only option that includes a category 1 preferred medication for favorable risk disease. Ipilimumab + nivolumab would be a preferred option in intermediate/poor risk disease, while cabozantinib would be an alternate therapy in intermediate/poor risk patients. Lenvatinib plus everolimus is an option in the second line setting.

LB is a 35 YOM with acute myeloid leukemia (AML) s/p HiDAC consolidation (high-dose cytarabine). On day 15 following chemotherapy, he wakes up with chills and shortness of breath. He measures his temperature and has a fever of 39.2°C. LB goes directly to the emergency department. Further workup reveals an absolute neutrophil count of 0.1 x 109 cells/L, blood pressure of 82/54 mm Hg (baseline 120/80 mm Hg), heart rate of 124 BPM, and respiratory rate of 26 breaths per minute. A chest X-ray is significant for a right lower lung opacification concerning for pneumonia, and blood and urine culture results are pending. His creatinine clearance exceeds 60 mL/min. He has no allergies and no other past medical history except that his AML induction course was complicated by a methicillin-resistant Staphylococcus aureus bloodstream infection. His MASCC score is 19. Which of the following is the most appropriate treatment for LB at this time? A. Ciprofloxacin + amoxicillin/clavulanate B. Levofloxacin + vancomycin C. Cefepime + vancomycin D. Meropenem + tobramycin

Correct Answer = C (cefepime + vancomycin) Rationale for correct answer: LB has a MASCC score < 21, so inpatient management of febrile neutropenia is warranted. Antipseudomonal beta-lactam monotherapy is recommended by the ASCO/IDSA and NCCN guidelines. Although cefepime is an appropriate choice, the ASCO/IDSA and NCCN guidelines recommend the addition of empiric vancomycin for patients with febrile neutropenia and hemodynamic instability, pneumonia, skin soft tissue infection, blood cultures with gram-positive organisms, concern for central venous access device infection, or colonization with MRSA or beta-lactam-resistant pneumococci. LB does have an indication for use of vancomycin (pneumonia, hemodynamic instability, and history of MRSA infection), so vancomycin should be added to his empiric regimen.

LJ is a 62 yo female presenting to the ED with a WBC 0.5 x 109/L and platelets 10 x 109/L. She has no past medical history and states she is training for the Boston marathon next month. Unfortunately, she is diagnosed with AML that is found to have a complex karyotype, an IDH1 mutation, and is CD33+. Which of the following treatments is most appropriate? A. Gemtuzumab B. Ivosidenib C. Azacitidine + venetoclax D. Decitabine + enasidenib

Correct Answer = C Azacitidine + venetoclax is an NCCN recommended treatment option for patients who are > 60 years of age and fit for intensive therapy but harbor unfavorable cytogenetics (ie: a complex karyotype). A: Gemtuzumab as a single agent would not be appropriate due to a) it is a therapy recommended for older patients who are unfit, b) response rates, EFS, and OS would likely be less than azacitidine + venetoclax, especially in patients with unfavorable cytogenetics. B: Although LJ has an IDH1 mutation she is relatively young and very fit, thus she should is eligible for a slightly more intense regimen than single agent ivosidenib. Ivosidenib is appropriate for patients with an IDH1 mutation who are elderly and unfit for other therapies. The response rates are significantly lower than azacitadine + venetoclax. D: Enasidenib is an IDH2 inhibitor. It would not be appropriate for patients with an IDH1 mutation. The combination of decitabine and enasidenib is currently being studied but not yet a recommended combination in the NCCN guidelines.

RO is a 64-year-old female with a history of DLBCL treated with CHOP. She is admitted due to symptoms of newly-diagnosed AML; NPM1, FLT3-ITD, and FLT3-TKD mutation negative; CD33+. Her cytogenetics reveal del7. Prior to her admission she was running 5 kilometers per day. She was treated with Liposomal cytarabine and daunorubicin. Ten days following confirmation of complete remission from induction, RO is to receive post-remission therapy. Renal and hepatic function are normal. Which of the following treatments is most appropriate? A. Cytarabine 3,000 mg/m2/dose IV Q12 hours on days 1,3,5 B. Cytarabine 1,000 IV Q12 hours on days 1,3,5 mg/m2/dose + gemtuzumab 3 mg/m2 C. Liposomal daunorubicin 29 mg/m2 and cytarabine 65 mg/m2 D. 5+2 (cytarabine continuous infusion x5 days + daunorubicin IV on days 1,2)

Correct Answer = C [daunorubicin 29 mg/m2 and cytarabine 65 mg/m2]. The phase III trial leading to FDA approval and a category 1 recommendation in the NCCN employed liposomal daunorubicin 29 mg/m2 and cytarabine 65 mg/m2 as consolidation for those who achieved a CR/CRi following liposomal daunorubicin/cytarabine induction. This regimen demonstrated an overall survival benefit compared with 7+3 induction and 5+2 consolidation. A: Although this is an NCCN guideline recommended consolidation strategy for AML consolidation and a standard of care, it was not studied with liposomal daunorubicin/cytarabine. It would be appropriate following 7+3 induction. B: Intermediate dose cytarabine is appropriate for older patients who are deemed unable to tolerate high-dose cytarabine. However, given the induction strategy employed was liposomal daunorubicin/cytarabine, this consolidation regimen would be incorrect. D: The phase III trial leading to FDA approval and a category 1 recommendation in the NCCN employed liposomal daunorubicin 29 mg/m2 and cytarabine 65 mg/m2 as consolidation for those who achieved a CR/CRi following liposomal daunorubicin/cytarabine induction. This regimen demonstrated an overall survival benefit compared with 7+3 induction and 5+2 consolidation.

AP is 68 YOF with multiple myeloma who is receiving treatment with lenalidomide, bortezomib, and dexamethasone (RVD). She presents to the infusion clinic today for her bortezomib injection and reports diarrhea with 12 bowel movements in the last 24 hours. WBC = 15 x 109 cells/L. She has a temperature of 38.3°C, BP 120/75, and SCr 0.65 mg/dL (baseline 0.5 mg/dL). She has a history of receiving levofloxacin for pneumonia two weeks ago. Workup includes testing for C. difficile toxin and antigen, which were positive. Which of the following is the most appropriate treatment for AP at this time? A. Vancomycin 500 mg PO and rectally Q6H + metronidazole 500 mg IV Q8H B. Vancomycin 125 mg PO and rectally Q6H + metronidazole 500 mg PO Q8H C. Metronidazole 500 mg PO Q8H D. Fidaxomicin 200 mg PO BID

Correct Answer = D (Fidaxomicin 200 mg PO BID) Rationale for correct answer: Vancomycin or fidaxomicin are recommended BY IDSA/SHEA and NCCN guidelines for treatment of initial CDI episode. Concomitant vancomycin and metronidazole would be indicated for fulminant infection (hypotension or shock, ileus, megacolon) per IDSA/SHEA guidelines, and only patients with an ileus should receive vancomycin rectally as well. As this patient does not have fulminant CDI, fidaxomicin monotherapy is the most appropriate choice from the listed options.

BL is a 55 YOF with breast cancer who is day 10 s/p dose dense AC (doxorubicin and cyclophosphamide). Her chemotherapy cycle has been complicated by culture-negative febrile neutropenia (high-risk due to MASCC score < 21, CISNE score = 3) with chest x-ray findings suggestive of pneumonia. She required hospitalization and received empiric treatment with piperacillin/tazobactam for a total of 3 days. She has been afebrile for 48 hours and has now recovered her neutrophil count. Your team would like to know when it would be appropriate to discontinue BL's antibacterials. Which of the following is the most appropriate response at this time? A. Discontinue piperacillin/tazobactam since neutropenia has resolved B. Continue piperacillin/tazobactam since BL has not received an adequate course for FN C. Continue piperacillin/tazobactam since BL has not received an adequate course for pneumonia D. De-escalate to oral step-down therapy since BL has not received an adequate course for pneumonia

Correct Answer = D (de-escalate to oral step-down therapy since BL has not received an adequate course for pneumonia) Rationale for correct answer: Since the patient has neutrophil recovery, she can be considered similar to a general patient with pneumonia. Thus, it would be appropriate to de-escalate to oral antibiotics to facilitate discharge where she can complete a course at home.

TS is a 19 YOF with relapsed ALL who just completed her first cycle of blinatumomab. She was recently discharged and found to be in a complete molecular remission. Which of the following is the most appropriate recommendation to provide the medical team at this time regarding vaccinations for TS? A. Influenza-inactivated vaccine can be administered to TS starting ≥ 3 months post blinatumomab B. Live influenza vaccine can be administered to TS starting ≥ 6 months post blinatumomab C. TS can receive the inactivated polio vaccine now since blinatumomab is not myelosuppressive D. Immunoglobulins will be suppressed for ~ 1 year following blinatumomab; consider monitoring antibody level if inactivated viruses administered

Correct Answer = D (immunoglobulins will be suppressed for >1 year following blinatumomab, consider monitoring antibody level if inactivated viruses administered) Rationale for correct answer: NCCN Guidelines discuss evidence regarding the lack of humoral response with blinatumomab and CAR-T cell therapy. It generally takes a year (or more) for B cell recovery and resolution of hypogammaglobinemia. Thus, if inactivated viruses are administered, one should monitor antibody levels.

BA is a 22 YOM with B-cell ALL receiving induction chemotherapy with CALGB 10403 (daunorubicin, vincristine, pegaspargase, and prednisone). He is day 21 of chemotherapy and has been neutropenic for the last 14 days. He is receiving antifungal prophylaxis with fluconazole 400 mg PO daily and continues on empiric FN treatment with cefepime 2g IV Q8H. Further diagnostic workup reveals a chest CT with several nodular opacities and a halo sign. Bronchoscopy with BAL reveals a positive galactomannan antigen from BAL fluid. Which of the following is the most appropriate treatment for BA at this time? A. Continue fluconazole B. Switch fluconazole to voriconazole C. Switch fluconazole to micafungin D. Switch fluconazole to liposomal amphotericin B

Correct Answer = D (switch fluconazole to liposomal amphotericin) Rationale for correct answer: BA has been diagnosed with probable IA based on positive imaging findings and serologic marker (galactomannan antigen) in a patient with prolonged, profound neutropenia (host factor). Although voriconazole is the gold-standard for treatment of IA, this patient is receiving vincristine (major CYP3A4 substrate). Strong CYP3A4 inhibitors should not be used concomitantly with vincristine, so an alternative should be selected. Echinocandins are not recommended as initial treatment, and continuing fluconazole at this time would not be appropriate. Thus, switching to liposomal amphotericin is the most appropriate.

JD is a 33 YOM with relapsed ALL currently receiving blinatumomab salvage therapy. JD's antimicrobial prophylaxis regimen includes levofloxacin 500 mg PO daily, fluconazole 400 mg PO daily, valacyclovir 500 mg PO daily, and dapsone 100 mg PO daily. On day 15, JB develops FN (ANC = 0.1 x 109 cells/L) with a temperature to 39°C. A chest CT obtained after four consecutive days of fever demonstrates large and numerous nodules with a halo sign. A bronchoscopy is performed and reveals a positive galactomannan antigen assay. Which of the following is the most appropriate treatment for JD at this time? A. Continue fluconazole B. Switch fluconazole from PO to IV C. Switch fluconazole to micafungin D. Switch fluconazole to voriconazole

Correct Answer = D (switch fluconazole to voriconazole) Rationale for correct answer: Voriconazole is the gold-standard treatment of Aspergillus spp. infections. This patient has imaging and serologic markers consistent with aspergillosis, thus voriconazole is warranted. Fluconazole would not cover Aspergillus spp., and echinocandins are not recommended as initial treatment per the IDSA Practice Guidelines for the Diagnosis and Management of Aspergillosis.

Correct Answer = D [Liposomal cytarabine and daunorubicin] - RO has secondary AML (previous exposure to CHOP) and is > 60 years of age. The NCCN guidelines recommend liposomal cytarabine and daunuribicin as a category 1 recommendation. A: A Phase III trial compared liposomal cytarabine and daunorubicin to 7+3 (daunorubicin 60 mg/m2) in patients >60 years of age who were fit for intensive chemotherapy. The liposomal formulation led to an overall survival benefit compared with 7+3. Additionally, 45 mg/m2 of daunorubicin is not an acceptable option due to a study by Fernandez et al NEJM 2009 demonstrating an overall survival benefit of 90 mg/m2 versus 45 mg/m2 B: A Phase III trial compared liposomal cytarabine and daunorubicin to 7+3 (daunorubicin 60 mg/m2) in patients >60 years of age who were fit for intensive chemotherapy. The liposomal formulation led to an overall survival benefit compared with 7+3. C: Despite RO being CD33+, there are several reasons to not add gemtuzumab. 1) this has not been adequately studied 2) there could be significant toxicity related to combined myelosuppression 3) patients with secondary AML do not response well to gemtuzumab / patients with poor risk cytogenetics (del7) do not respond well to gemtuzumab.

DH is a 26 year-old male with complaints of bone pain, early satiety and frequent headaches. WBC 80.4 x109/L w/ 40% blasts. He is diagnosed with Philadelphia chromosome-positive pre-B cell ALL,. Which of the following is the optimal remission induction therapy? A. CALGB 10403 B. CALGB 9511 C. Mini-CVD + inotuzumab + ponatinib D. HyperCVAD + ponatinib

Correct Answer =D HyperCVAD + ponatinib - this is an NCCN recommended regimen based on a single center phase II experience showing exceptionally long event and overall survival A. Although DH is a young adult the C10403 trial did not include Philadelphia chromosome-positive ALL. Additionally, DH requires a tyrosine kinase inhibitor. B. C9511 trial did not include Philadelphia chromosome-positive ALL. Additionally, DH requires a tyrosine kinase inhibitor. C. Mini-CVD + inotuzumab + ponatinib is not an appropriate option as the combination of inotuzumab with ponatinib does not have robust data to support it is safe to combine. Mini-CVD with inotuzumab without ponatinib is also not appropriate as this regimen was designed for older patients and is one of the many options recommended by NCCN for older patients with ALL. The regimen backbone is supported by only single center Phase II data.

JF is a retired 68-year-old male with a history of chronic kidney disease, hypertension and hypercholesterolemia. He was in his usual state of health until approximately 6 months ago, when he noted significant and painful lymph node swelling in his neck and groin. His family medical doctor prescribed an antibiotic, but his symptoms did not resolve. He returned to his family doctor, where his CBC revealed marked lymphocytosis (lymphocytes = 27,000 B cells/mm3). Flow cytometry confirmed the diagnosis of CLL. After further workup, JF is diagnosed with Binet stage B disease. His cytogenetic analysis reveals that he has a del(13q) mutation and unmutated IGHV. He is considered medically fit to receive treatment. Which of the following treatment regimens is the most appropriate first-line therapy for FB? A. Acalabrutinib +/- obinutuzumab B. Chlorambucil + ofatumumab C. Fludarabine, cyclophosphamide and rituximab (FCR) D. Alemtuzumab + rituximab

Correct answer = A (Acalabrutinib +/- obinutuzumab). This patient is over 65 years of age and has chronic kidney disease, making him ineligible for fludarabine-based chemoimmunotherapy regimens in the first-line setting. Acalabrutinib +/- obinutuzumab has a NCCN Guidelines® Category 1 recommendation in this setting based on the results of the ELEVATE-TN trial. Treatment with ofatumumab is only recommended in the relapsed and refractory setting. Alemtuzumab is not recommended in the first-line setting in patients without del(17p).

DH is diagnosed with Philadelphia chromosome-positive pre-B cell ALL and began HyperCVAD, arm "A" with a TKI. On day 2 of chemotherapy, his labs were notable for WBC 42 x 109/L, BUN 36 mg/dL, serum creatinine 2.2 mg/dL, potassium 5.7 mEq/L, phosphate 4.9 mg/dL, LDH 2810 IU/L and uric acid 8.6 mg/dL. Along with allopurinol, which of the following is most appropriate to manage tumor lysis risk in DH? A. Aggressive hydration with normal saline B. Rasburicase C. Sodium polystyrene sulfonate D. Consult for emergent renal dialysis

Correct answer = A (Aggressive hydration with normal saline). The most important medication for treatment of TLS is intravenous fluid, infused at a rapid rate. This not only dilutes electrolytes, but helps maintain optimal renal function to excrete electrolytes, including potassium and uric acid. The use of rasburicase and sodium polystyrene sulfate is important in the management of TLS, but should occur after intravenous fluids have been maximized

FB is a 71-year old male with CLL who has been receiving ibrutinib for the past 18 months. Over the past two weeks, he has noted rapidly enlarging cervical, axillary and inguinal lymphadenopathy. He also reports new fevers, splenomegaly and unintentional weight loss. Which of the following is the most likely the cause of FB's new complaints? A. Richter's transformation B. Ibrutinib resistance C. Redistribution lymphocytosis D. Tuberculosis infection

Correct answer = A (Richter's transformation). The rapid onset, nature and severity of FB's symptoms suggests a transformation to a more aggressive malignancy, commonly known as histologic transformation or Richter's transformation (RT). While ibrutinib resistance does occur, the onset is often insidious. Redistribution lymphocytosis occurs early in a patient's treatment course and would not occur after 18 months of therapy. Tuberculosis infection is not associated with ibrutinib.

DG is a 63-year old male who is receiving idelalisib + rituximab for the treatment of relapsed CLL. He has no known drug allergies. What supportive care measure should DG receive to prevent complications from his underlying disease and/or treatment regimens? A. Sulfamethoxazole - trimethoprim B. Zostavax® C. Ganciclovir D. IVIG

Correct answer = A (Sulfamethoxazole - trimethoprim). Sulfamethoxazole - trimethoprim (or an equivalent) is recommended as Pneumocystis jiroveci pneumonia (PJP) prophylaxis with sulfamethoxazole-trimethoprim or an equivalent is recommended for patients receiving purine analogs, bendamustine, idelalisib, duvelisib or alemtuzumab. DG has received both fludarabine and idelalisib as treatment for his CLL so this would be an appropriate supportive care medication to initiate. The use of prophylactic ganciclovir would not be warranted unless DG had CMV viremia present at the initiation of therapy. Live vaccines such as Zostavax® should be avoided in patients with CLL. Finally, IVIG would only be appropriate if DG had suffered recurrent infections and had an IgG level <500 mg/dL.

TK is a 72-year-old male with multiple comorbidities including diabetes, hypertension, atrial fibrillation and low grade MDS. He is currently being treated with best supportive care due to a PS of 3 and consequently has received more than 30 blood transfusions in addition to daily iron supplementation. He presents with complaints of shortness of breath and abdominal pain. His labs are as follows: WBC 3300 cells/mm3 with 45% neutrophils, hemoglobin 9 gm/dL and platelets 121,000 cells/mm3, serum creatinine 1.1 mg/dL, total bilirubin 0.8 mg/dL, ferritin 3100 ng/ml. Which of the following is the most likely cause of TK's current symptoms? A. Untreated iron overload B. Invasive pulmonary aspergillosis C. Sinusoidal obstructive syndrome D. Adverse drug reaction to iron supplements

Correct answer = A (Untreated iron overload). Best supportive care for low grade MDS includes support with red blood cell transfusion. TK's signs and symptoms suggest iron overload, which is a potential problem with repeated red blood cell transfusions. Thus, the correct answer is A. TK should be started on iron chelation therapy such as deferoxamine or deferasirox. Answer B is incorrect because despite having MDS this patient's neutrophil count is preserved; thus he is not at high risk for invasive aspergillus. Additionally, no other diagnostic information was given to confirm invasive aspergillus infection (ie: CT scan, galactomannan, or histopathological/culture data). Answer C is incorrect as no information was given to suggest sinusoidal obstructive syndrome (ie: significant weight gain, hyperbilirubinemia, hepatomegaly, etc). Answer D is incorrect because TK's symptoms would not be an adverse reaction to the oral iron replacement and would not lead to iron overload when taken in normal amounts.

LP is a 42-year-old female who has always enjoyed excellent health. She takes no medications other than an over-the-counter NSAID for sporadic migraine headaches. She presented for a physical examination as required by her new insurance plan, where her blood work was remarkable for a WBC of 94,000 cells/mm3, platelets of 197,000 cells/mm3 and a hemoglobin of 13.1 g/dL. Her serum chemistries were all within normal limits. She has been referred to a hematologist for further workup. LP is examined by the hematologist and consents to a bone marrow biopsy. The biopsy is notable for marked hypercellularity. Cytogenetic analysis is positive for t(9;22), confirming the diagnosis of chronic phase CML. She is considered to have intermediate-risk disease according to her ELTS score. Which of the following is the most appropriate initial therapy for LP? A.Imatinib B.Bosutinib C.Ponatinib D.Allogeneic stem cell transplant

Correct answer = B (Bosutinib). Since LP has intermediate-risk, chronic phase disease, the NCCN Guidelines® Category 1 recommendations for first-line treatment are dasatinib, nilotinib or bosutinib. Imatinib could also be considered as an acceptable option, although it is not the most appropriate choice in this case since it is not a Category 1 recommendation. Ponatinib and allogeneic stem cell transplantation are recommended in the second- or third-line setting, or in the presence of specific mutations.

DG is a 63-year old male with relapsed CLL. He is not a candidate for ibrutinib, and thus he was planning to start venetoclax + rituximab. However, he cannot afford venetoclax + rituximab, so he will initiate idelalisib + rituximab instead. Which of the following statements about idelalisib is correct? A. Pancreatitis is common. B. Diarrhea may be severe. C. Lower extremity edema often occurs. D. Visual changes are frequent.

Correct answer = B (Diarrhea may be severe). Severe diarrhea or colitis occurs in approximately 10% of patients who receive idelalisib. Pancreatitis, lower extremity edema and visual changes are not common adverse effects of this agent.

CJ is a 69 year-old female with no significant medical history. Despite generally enjoying good health for most of her life, she has noticed an increase in fatigue for the last 2 weeks. When she presented to her primary care provider, her laboratory parameters revealed WBC 2300 cells/mm3 with 40% neutrophils, hemoglobin 6.1 gm/dL and platelets 138,000 cells/mm3. She was given 2 units of packed red blood cells (RBCs) and referred to a hematologist. Bone marrow biopsy was obtained and comes back from with a reading of dysplastic changes with ringed sideroblasts and 4% blasts consistent with de novo MDS. Cytogenetics reveal a normal karyotype and molecular studies are positive for an SF3B1 mutation. Her epoetin level is reported as 640 units/L. Over the past 2 months she has required 2 units of RBCs every other week. Her IPSS-R category is low-risk. Based upon this information, which of the following agents is the most appropriate to initiate in CJ? A. Erythropoietin B. Luspatercept C. Eltrombopag D. Lenalidomide

Correct answer = B (Luspatercept). Luspatercept is indicated for low risk MDS with ringed sideroblasts in patients who have failed or are unlikely to respond to ESAs. Given our patient's EPO level is > 500 she is unlikely to respond to an ESA (A is incorrect). C is not correct because she does not have thrombocytopenia. D is not correct because she does not have del 5q and her epoetin level is too high to consider lenalidomide for non-del5q MDS.

VM is a 46-year-old male who was diagnosed with Philadelphia chromosome positive CP-CML four years ago. He does not have any genetic mutations. He was initially started on imatinib, but was changed to dasatinib when he did not achieve a complete cytogenetic response after 12 months. He developed a pleural effusion while taking dasatinib, and is unable to take nilotinib due to a major drug interaction with his concurrent medications. After being off therapy for the past four months, his most recent bloodwork revealed t(9;22) as well as trisomy 8 and isochromosome 20q, confirming the conversion to accelerated phase. What is the most appropriate therapy for VM at this point in time? A. Ponatinib B. Omacetaxine C. Allogeneic stem cell transplantation D. Autologous stem cell transplantation

Correct answer = B (Omacetaxine). The patient has failed or is unable to tolerate imatinib, dasatinib and nilotinib. Current recommendations for AP-CML in this patient would include bosutinib or omacetaxine (note that omacetaxine is only recommended in patients who progress to accelerated phase, not in those who present in accelerated phase). Ponatinib is not currently recommended in CML-AP unless the patient has the T315I mutation. Allogeneic HSCT should be considered if the patient is able to achieve a second chronic phase, but there are no recommendations for autologous HSCT in CML in any phase of disease.

While awaiting cytogenetic analysis of a bone marrow sample from a MDS patient, your collaborating physician asks you if there is an oral option available to treat MDS. Lenalidomide is an option. However, lenalidomide is most appropriate in an MDS patient with which of the following cytogenetic features? A. Del(12p) B. Del(5q) C. FLT3-ITD D. Normal Cytogenetics

Correct answer = B [Del(5q)]. In a Phase II study, patients who received lenalidomide and had a deletion of 5q benefited most from lenalidomide. FLT3-ITD mutations respond to FLT3 inhibitors, not lenalidomide. Additionally, FLT3 inhibitors have been approved for acute myeloid leukemia but not for MDS.

LJ received ATRA + arsenic trioxide + gemtuzumab for his high-risk APL. On day 15 of LJ's treatment, his WBC is 0.1 x 109/L and bilirubin is 4.5 mg/dL. He exhibits fevers, a 10% weight gain, painful hepatomegaly. An ultrasound is performed revealing ascites and reversal of portal flow. Chest-radiograph is unremarkable. Which of the following best describes LJ's symptoms? A. Coagulopathy B. Urosepsis C. Sinusoidal obstruction syndrome D. Differentiation syndrome

Correct answer = C LJ is experiencing sinusoidal obstruction syndrome (SOS) formally known as veno-occlusive disease. A well-known side effect of gemtuzumab is SOS. The specific characteristics are discussed in the BMT chapter but it is also important to understand for those using gemtuzumab or inotuzumab in leukemia. A: No signs or symptoms are present demonstrating bleeding/thrombosis/coagulopathy B: There are overlapping signs/symptoms of sepsis and SOS, however, the reversal of portal flow in additional to the other signs/symptoms are consistent with SOS D: There are overlapping signs/symptoms of differentiation syndrome and SOS. Both should be on high suspicion in a patient receiving ATRA + Arsenic + gemtuzumab. However, the lack of pulmonary infiltrates (generally caused by third spacing in differentiation syndrome), the elevated bilirubin, the painful hepatomegaly, ascites with reversal of portal flow are not common with differentiation syndrome. Additionally, although it is possible for differentiation syndrome symptoms to occur when a white count is nearly undetectable, it is less common.

LP is a 42 yo F w chronic phase CML, started on bosutinib 400 mg PO daily. After 12 months of therapy, she has not achieved a complete cytogenetic response. Drug interactions and non-adherence with therapy have been ruled out. What is most appropriate second-line treatment of chronic phase disease for LP at this point in time? A.Increase bosutinib to twice daily B.Change to high-dose imatinib C.Change to dasatinib D.Change to ponatinib

Correct answer = C (Change to dasatinib). LP has failed to meet established milestones for treatment response, so it would be inappropriate to continue her current therapy of bosutinib; further, there is no evidence that increasing the dose of bosutinib to twice daily dosing provides an improved response in chronic phase CML. If a second-generation TKI is used in the first-line setting, another second-generation TKI should be used in the second-line setting; it would inappropriate to change to the first-generation TKI imatinib in this scenario. In addition, the dose of imatinib in this question is "high dose;" dose escalation of imatinib is unlikely to benefit patients who never achieved a cytogenetic response with standard dose imatinib. Ponatinib is only indicated in patients who harbor the T315I mutation.

JF is a 68 year old male with newly diagnosed CLL who will be initiating therapy with acalabrutinib. Which of the following adverse effects are frequently seen with acalabrutinib and should be discussed during your counseling session with JF? A. Hypotension B. Tumor lysis syndrome C. Headache D. Periorbital edema

Correct answer = C (Headache). Headache is the most commonly reported adverse effect of acalabrutinib treatment, occurring in up to 40% of patients. This effect is usually transient and can be mitigated with fluids, caffeine, and treatment with NSAIDs or other agents. Acalabrutinib is associated with hypertension, but hypotension has not been reported. Tumor lysis syndrome is associated with venetoclax, not acalabrutinib. Periorbital edema is commonly seen with imatinib therapy, but not acalabrutinib.

DG is a 63-year old male with CLL with del(11q). His past medical history is significant for hypothyroidism, well-controlled atrial fibrillation and gastroesophageal reflux disease. He received treatment with FCR three years ago and achieved a complete response. He did not receive lenalidomide maintenance and has been followed by observation. After experiencing a recurrence of painful cervical lymphadenopathy, he has recently been diagnosed with relapsed CLL. Which of the following regimens is most appropriate for DG at this point in his course? A. Repeat FCR B. Ibrutinib C. Venetoclax + rituximab D. Bendamustine, rituximab + idelalisib

Correct answer = C (Venetoclax + rituximab). Of the proposed choices, venetoclax + rituximab is the most appropriate. This regimen has an NCCN Guidelines® Category 1 recommendation for use in the second-line setting based on the results of the MURANO study. Ibrutinib also has an NCCN Guidelines® Category 1 recommendation in this setting, but DG has a history of atrial fibrillation and the association of ibrutinib and atrial fibrillation is well-documented. Repeating FCR would not be the most appropriate as there are more effective choices for second-line treatment. The combination of bendamustine, rituximab and idelalisib is a Category 2B recommendation at this time and therefore is not the most appropriate choice of the proposed options

DH is a 26 year-old male with complaints of bone pain, early satiety and frequent headaches. WBC 80.4 x109/L w/ 40% blasts. He is diagnosed with Philadelphia chromosome-positive pre-B cell ALL,. Was treated with HyperCVAD + ponatinib. Bone marrow biopsy after hematopoietic recovery from remission induction therapy revealed positive minimal residual disease. Which of the following is most appropriate to treat DH with at this time? A. Inotuzumab ozogamicin B. Nelarabine C. Continue hyperCVAD + ponatinib D. Blinatumomab

Correct answer = C (continue hyper-cvad with ponatinib) Based on the BLAST trial, North American MRD guidelines, and other MRD primary literature blinatumomab should be initiated if MRD+ following 3 cycles of intensive therapy, NOT after induction (especially for a patient with Ph+ disease). Given this patient has only received 1 cycle of chemotherapy, he can continue on with the current regimen to Part B of hyper-CVAD with ponatinib. Inotuzumab ozogamicin would only be appropriate in fulminant relapsed or refractory disease. Nelarabine would not be appropriate because DH has B-cell ALL (not T-cell ALL).

SK is a 64 yo F w FIGO grade 1 endometrioid adenocarcinoma as well as cervical intraepithelial neoplasia grade 1 at 10. SK undergoes primary surgical management with a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and biopsies. SK received EBRT and brachytherapy followed by active surveillance. At her follow-up she reports feeling well other than shortness of breath she contributes to an ongoing cold. Unfortunately, laboratory tests show an elevated CA-125 and prompting imaging which reveals lung, pelvic and para-aortic metastases. Which of the following is the most appropriate treatment for SK at this time? a. Chemotherapy b. Hormone therapy c. Surgical resection d. Radiation therapy

Correct answer is A, SK has symptomatic disseminated metastases; therefore, chemotherapy would be most appropriate at this time. Answer B would not be most appropriate as hormone therapy would only be considered in a patient with asymptomatic disseminated metastases or poor performance status. Answer C and D would not be appropriate as SK has disseminated metastases and according to the NCCN Guidelines® pharmacologic intervention is most appropriate

EH has metastatic colorectal cancer and agreed to receive FOLFIRI + bevacizumab and presents today to begin treatment. During the irinotecan infusion, he experiences abdominal cramping and diaphoresis. He also experiences an episode of diarrhea. What is the most appropriate intervention to alleviate EH's symptoms? A. Give atropine, and consider pre-medication with atropine for future cycles B. Give loperamide, and counsel EH to take loperamide around the clock at home C. Give octreotide, and consider pre-medication with octreotide for future cycles D. Give tincture of opium, and counsel EH to take tincture of opium around the clock at home

Correct answer is A. Acute irinotecan-associated diarrhea is a cholinergic reaction; therefore, atropine is the most appropriate treatment to alleviate EH's symptoms. Answer B is incorrect because loperamide will not alleviate the cholinergic reaction of acute irinotecan diarrhea. Loperamide can be considered for delayed diarrhea. Answer C is incorrect because octreotide will not alleviate the cholinergic reaction of acute irinotecan diarrhea. Octreotide can be considered for complicated delayed diarrhea or diarrhea that is refractory to loperamide. Answer D is incorrect because tincture of opium will not alleviate the cholinergic reaction of acute irinotecan diarrhea. Tincture of opium can be considered for use in persistent, uncomplicated diarrhea.

HZ is a 47-year-old postmenopausal female who was diagnosed with ER-positive, PR-negative, HER2-negative stage 1A invasive ductal carcinoma 2 years ago. She was treated with a breast-conserving surgery followed by radiation and anastrozole. She presents to her medical oncologist for follow-up after 18 months of receiving anastrozole. She is noted to have new onset back and hip pain, which is due to metastatic breast cancer to the bone. The pathology of the metastatic site is also ER-positive, PR-negative, and HER2-negative. The tissue sample of the metastatic lesion is also found to be PIK3CA-mutated and BRCA-negative. What is the most appropriate option to treat HZ's metastatic breast cancer? A. Alpelisib and fulvestrant B. Everolimus C. Doxorubicin and cyclophosphosphamide (AC) D. Olaparib

Correct answer is A. Alpelisib is a PIK3CA inhibitor that is indicated in combination with fulvestrant for postmenopausal women with HR-positive, HER2-negative, PIK3CA-mutated advanced or metastatic breast cancer that have progression on or after an endocrine-based regimen. HZ meets this criteria since she had progression while receiving adjuvant anastrozole. NCCN Guidelines® consider alpelisib and fulvestrant a category 1 regimen for patients with PIK3CA-mutated advanced or metastatic breast cancer. Answer B is incorrect because everolimus as a single-agent is not indicated for the treatment of metastatic breast cancer. Answer C is incorrect because chemotherapy could be considered in this patient at some point in her treatment; however, alpeslib and fulvestrant is a more appropriate option given her PIK3CA-mutated disease and lack of visceral crisis. Answer D is incorrect because olaparib is only an appropriate option for patients with recurrent or metastatic HER2-negative, BRCA1/2-positive breast cancer. HZ has BRCA-negative breast cancer.

SM has clinical stage IVB (pleural effusions and liver lesions) ovarian cancer and is deemed upon imaging and in consultation with surgery to be unlikely to be optimally cytoreduced. SM completed 3 cycles of neoadjuvant chemotherapy, underwent interval debulking surgery attaining optimal cytoreduction, and subsequently completed 3 more cycles of adjuvant chemotherapy with paclitaxel and carboplatin, achieving a complete response. SM presents to clinic 2 years after completing adjuvant chemotherapy which was complicated by grade 2 peripheral neuropathy. She has remained on niraparib maintenance but due to recent symptoms of abdominal distension, a CT scan was completed revealing new lymphadenopathy and confirmed disease recurrence. SM states that she is concerned about worsening peripheral neuropathy with receiving treatment again. Which of the following regimens is most appropriate for SM? a. IV carboplatin + gemcitabine b. IV carboplatin + paclitaxel c. IV liposomal doxorubicin + bevacizumab d. IV cisplatin + gemcitabine

Correct answer is A. Although carboplatin could worsen the patient's peripheral neuropathy, platinum-based combination chemotherapy is recommended for patients with platinum-sensitive disease. Carboplatin can be given with either gemcitabine or liposomal doxorubicin +/- bevacizumab in lieu of paclitaxel to prevent further exacerbation of peripheral neuropathy. Answer B is inappropriate as the patient had grade 2 neuropathy with previous treatment and explicitly expressed concern regarding this potential adverse effect. Therefore, exposing her to paclitaxel again is not ideal. Answer C is inappropriate therapy for a patient with platinum-sensitive disease in the first relapse. This could be considered in a patient with platinum-resistant disease. Answer D is inappropriate as cisplatin would be expected to cause more neuropathy than carboplatin.

Correct answer is A. DS is a candidate to receive palbociclib and letrozole for her HR-positive, HER2 negative metastatic breast cancer. She should be counseled to take letrozole daily on a continuous basis and palbociclib daily with food on days 1-21 every 28 days (3 weeks on, 1 week off). Other acceptable options include single agent endocrine therapy (AI, fulvestrant, or tamoxifen), fulvestrant ± AI, or fulvestrant ± CDK 4/6 inhibitor. If DS was symptomatic from her lung metastasis, then chemotherapy would be a reasonable option. Answer B is incorrect because everolimus and exemestane are indicated after failure of nonsteroidal AI. Answer C is incorrect because goserelin is only indicated in premenopausal patients. Answer D is incorrect because trastuzumab is only indicated in HER2 positive disease.

HT is a 58-year-old female with a locally advanced adenocarcinoma of the esophagus. She received preoperative chemoradiation with carboplatin and paclitaxel which was followed by esophagectomy. She has been observed for the past year for disease progression and was found to have new liver metastases on the most restaging evaluation. HT received cycle 1 of chemotherapy with fluorouracil and irinotecan (FOLFIRI) and presents to the infusion center today for chemotherapy pump disconnection. She reports that the skin on her chest is red and painful to touch. The physician is concerned HT may be experiencing mild radiation recall. Which of the following management strategies is most appropriate for HT's mild radiation recall? A. Observation and continue therapy with no modifications B. Supportive care and continue therapy with dose reduction C. Steroid premedication and continue therapy with dose reduction D. High-dose steroids and discontinue therapy

Correct answer is A. Fluorouracil is a chemotherapy agent known to be associated with radiation recall. Symptoms can occur during or immediately after intravenous infusions, which is consistent with timing of the fluorouracil infusion and onset of symptoms. The area should be kept clean and dry and avoid excessive rubbing which may further irritate the skin. Supportive care with moisturizers, nonsteroidal anti-inflammatories, anti-histamines, or topical steroids may be considered if needed. Given that the patient is experiencing mild symptoms, it would be reasonable for her to continue receiving chemotherapy with close monitoring for worsening of symptoms. Answer B: Supportive care with moisturizers, nonsteroidal anti-inflammatories, anti-histamines, or topical steroids may be considered if needed. Dose reduction of therapy is indicated for severe skin reactions. Answer C: Steroid premedication can be considered, but dose reduction of therapy is indicated for severe skin reactions. Answer D: High-dose steroids are indicated for severe skin reactions or reactions affecting internal organs. Discontinuation of therapy is indicated for severe skin reactions.

CH is a 46-year-old postmenopausal Caucasian woman who presents to the clinic with a newly diagnosed left breast cancer found on screening mammogram. The breast mass measured 1.2 x 2.1 cm and her axillary lymph nodes were negative by ultrasound. Core biopsy of the breast mass indicates an invasive ductal carcinoma, nuclear grade 1 (well differentiated), ER = 70%, PR = 0%, HER2 IHC = 2+, HER2 FISH negative. CH has stage IIA disease (T2, N0, M0) that is ER -positive, HER2-negative and well differentiated. She has several good prognostic features (ER/PR-positive, HER2-negative). The goal of therapy for CH is cure. She plans to undergo primary surgery. If she were to have a lumpectomy, lymphatic mapping with SLNB would be the most appropriate option. Radiation therapy would be required with a lumpectomy. If this patient underwent a mastectomy, post-mastectomy radiation would only be considered if she were to have positive lymph nodes or close or positive surgical margins. CH elected to have a lumpectomy with surgical axillary staging. She has negative axillary nodes. Her pathologic stage is IIA (pT2, pN0, M0). The Oncotype DX recurrence score on the surgical specimen is 11. What is the most appropriate adjuvant therapy for CH according to NCCN Guidelines®? A. Anastrozole B. Docetaxel and cyclophosphamide (TC) followed by anastrozole C. Tamoxifen D. Docetaxel and cyclophosphamide (TC) followed by tamoxifen

Correct answer is A. Her oncologist discusses the significance of this low RS (11), which indicates that endocrine therapy alone is sufficient. Following her lumpectomy, CH is scheduled to start radiation to the whole breast with boost to the tumor bed along with endocrine therapy. NCCN Guidelines® recommend the incorporation of an aromatase inhibitor for postmenopausal women. Options include use of an aromatase inhibitor for 5-10 years, tamoxifen for 2-3 years followed by an aromatase inhibitor to complete 5 years of endocrine therapy, or tamoxifen for 5 years followed by an additional 5 years of therapy with an aromatase inhibitor or tamoxifen. All of these are appropriate options. If she could not tolerate an aromatase inhibitor, tamoxifen for 5 or 10 years would be an acceptable option. Answer B is incorrect because chemotherapy is not indicated for CH based on her low RS =11. Based on the results of the TAILORx trial, chemotherapy is not routinely recommended for patients with a RS of < 26. It can be considered for patients age ≤ 50 and RS 16-25. Anastrozole is an appropriate adjuvant endocrine therapy for CH. Answer C is incorrect because an AI is preferred for this patient. Tamoxifen is only indicated for postmenopausal women with an intolerance or contraindication to an aromatase inhibitor. Answer D is incorrect because chemotherapy is not indicated for CH based on her low RS =11. Based on the results of the TAILORx trial, chemotherapy is not routinely recommended for patients with a RS of < 26. It can be considered for patients age ≤ 50 and RS 16-25. Anastrozole is an appropriate adjuvant endocrine therapy for CH. Also, an AI would be preferred for this patient since she is postmenopausal. Tamoxifen is only indicated for postmenopausal women with an intolerance or contraindication to an aromatase inhibitor.

TS is a 36-year-old premenopausal white female who presents with a diagnosis of lobular carcinoma in situ (LCIS). She has a significant family history of breast cancer including her mother, maternal grandmother, and maternal aunt who were all diagnosed prior to 60 years of age. TS had one child at age 31 and no history of oral contraceptive use or estrogen replacement therapy. She was 12 years old at first menarche. A decision was made to calculate TS's lifetime risk of breast cancer using the Claus model and the result was > 20% lifetime risk. She declined to undergo genetic testing at this time. She was counseled that bilateral mastectomy +/- bilateral salpingo-oopherectomy is a recommended strategy for breast cancer risk reduction. Given that she is premenopausal, what is another appropriate risk reduction strategy according to NCCN Guidelines®? A. Tamoxifen B. Goserelin C. Anastrozole D. Raloxifene

Correct answer is A. TS's >20% lifetime risk of breast cancer and diagnosis of LCIS put her at a high-risk for development of breast cancer. Risk reduction strategies for TS include bilateral total mastectomy, bilateral salpingo-oophorectomy or chemoprevention with tamoxifen given that she is ≥ age 35. Salpingo-oophorectomy is an option if BRCA 1/2 mutation is strongly suspected. Answer B is incorrect because luteinizing hormone-releasing hormone (LHRH agonists) (including goserelin) are not appropriate as a risk reduction strategy. Answer C is incorrect because aromatase inhibitors are only indicated in postmenopausal women. Answer D is incorrect because raloxifene is only indicated in postmenopausal women. If TS were postmenopausal her options for risk reduction would include bilateral total mastectomy, or chemoprevention with tamoxifen, raloxifene, or an aromatase inhibitor. TS should receive screening according to high-risk guidelines. NCCN® screening recommendation for TS include CBE every 6 - 12 months, annual mammography, and annual breast MRI. ACS recommends annual mammography and breast MRI.

DD is a 55 year-old-female, ECOG status 0 who presents with complaints of severe fatigue, 6 months of post-menopausal bleeding and lab work revealing a Hgb of 7.8 g/dL. A pelvic ultrasound and endometrial biopsy reveal non-keratinizing squamous cell carcinoma, invasive, moderately to poorly differentiated, consistent with cervical origin. Surgical staging reveals a cervical lesion ~2 cm in diameter and firm with the uterus and cervix deviated left. On rectovaginal exam, there is left parametrium tethering and there is thickening of the parametrium, consistent with parametrial invasion. Cystoscopy and vaginal exam are normal. Unfortunately, imaging reveals rectal involvement not appreciated on exam; therefore, she has stage IVA cervical cancer. DD completed successful chemoradiation and has been under active surveillance. DD presents to her 2-year follow-up feeling great and her only complaint is a new onset of a persistent dry cough. A CT of her chest is notable for diffuse pulmonary nodules, consistent with metastatic cervical cancer. PD-L1 testing was attempted on a prior tissue sample but failed. Which of the following every 3 week treatment options would be most appropriate for DD according to the NCCN Guidelines®? A. Cisplatin 50 mg/m2 + paclitaxel 175 mg/m2 + bevacizumab 15 mg/kg B. Cisplatin 50 mg/m2 C. Topotecan 1.5 mg/m2 days 1-5 D. Pembrolizumab 200 mg

Correct answer is A. The most appropriate treatment for DD is combination chemotherapy with cisplatin, paclitaxel and bevacizumab as GOG-240 showed an improved overall survival with the addition of bevacizumab to combination chemotherapy. Answers B and C are not the most appropriate treatment options as multiple trials have demonstrated patients receiving 2-drug combinations for relapsed metastatic cervical cancer had higher response rates and improved progression-free survival compared to single agent therapy. Answer D is not the most appropriate treatment option as we do not know if DD's malignancy expresses PD-L1 or is MSI-H/dMMR.

GS is a 62 yo F with stage IIB ER-negative, PR-negative, HER2 positive (IHC 3+) breast cancer 10 years ago and received treatment with lumpectomy, adjuvant chemotherapy with TAC x 6 cycles, followed by radiation and 1 year of trastuzumab received docetaxel, trastuzumab, and pertuzumab x 8 months at which time she developed new metastases in her liver. Which of the following regimens is the most appropriate for GS at this time? A. Capecitabine + lapatinib B. Ado-trastuzumab emtansine C. Trastuzumab + lapatinib D. Lapatinib

Correct answer is B. Ado-trastuzumab emtansine (T-DM1) would likely be preferred since it has improved PFS and OS compared to capecitabine and lapatinib. There is also data to support the use of trastuzumab + capecitabine in this setting. Additional options include continuation of trastuzumab and changing the chemotherapy to vinorelbine. Continuation of pertuzumab after disease progression has not been evaluated. Answer A could be considered, but it is not the most appropriate option because the EMILIA study showed improved PFS and OS with ado-trastuzumab emtansine compared to capecitabine and lapatinib. Answer C is incorrect because GS should receive cytotoxic chemotherapy in addition to anti-HER2 therapy given the presence of visceral metastases. Answer D is incorrect because GS should receive cytotoxic chemotherapy in addition to anti-HER2 therapy given the presence of visceral metastases. Also, lapatinib is not recommended for use as single agent therapy.

GG is a 42-year-old man with a newly diagnosed anaplastic oligodendroglioma of the right temporal lobe. He underwent a sub-total resection. Mutational analysis showed, 1p19q codeletion, IDH-mutation and MGMT-methylation. What is the most appropriate therapy for GG at this time? A. Observation B. Radiation followed by procarbazine, lomustine (CCNU), and vincristine C. Temozolomide with concurrent radiation D. Temozolomide with concurrent radiation followed by temozolomide

Correct answer is B. GG has a new anaplastic oligodendroglioma with higher-risk features such as sub-total resection and age. Even though he is 1p19q codeleted and has an IDH-mutation, NCCN® preferred standard of care is radiation followed by PCV (procarbazine, lomustine, and vincristine). Answer A is incorrect because of his high-risk features. Answers C and D are preferred treatments for glioblastoma.

JA is a 67-year-old man who noted an enlarging mass in the right side of his neck. A total thyroidectomy was performed and pathology confirmed medullary thyroid carcinoma. The primary lesion was 2.9 cm along with multiple positive lymph nodes of the bilateral neck. He underwent surveillance for 3 years, but after continued elevation of calcitonin, he was started on vandetanib. According to the main trial supporting vandetanib use in MTC, what was the most concerning side effect that brought about required REMS program for its use? A. Fetal harm B. Prolonged QTc C. GI perforation D. Stevens-Johnson syndrome

Correct answer is B. In the ZETA trial, 19 patients (8%) experienced prolongation of QTc. Because of this prolongation and risk for Torsades de pointes as well as sudden death, vandetanib is only available from certified REMS providers.

Correct answer is B. Niraparib is the only PARP inhibitor approved for primary maintenance therapy following a CR or PR to platinum-based chemotherapy, independent of BRCA status. Answer A is not appropriate because bevacizumab maintenance therapy should be reserved for patients who received bevacizumab-containing primary therapy as per GOG-218 or ICON-7. Answer C is not appropriate because olaparib is recommended for use in patients with either somatic or germline deleterious or suspected deleterious BRCA1/2 alterations who are in a CR or PR to primary platinum-based chemotherapy. Answer D is not as appropriate because niraparib primary maintenance therapy is approved for use in patients independent of BRCA status.

LS is a 73-year old female who presents her PCP with complaints of abdominal cramping, dark stools, and feeling excessively fatigued. Laboratory results reveal a hemoglobin of 6.2 g/dL. A colonoscopy reveals a large, circumferential mass, mostly obstructing and unable to be traversed. CT scans of the chest, abdomen, and pelvis reveal no evidence of metastatic disease. LS therefore underwent a laparoscopic right colectomy. Pathology revealed a moderately differentiated adenocarcinoma, negative margins, 0/29 lymph nodes positive for disease, evidence of perineural invasion but no lymphovascular invasion, and microsatellite low. LS was staged with T4a N0 M0 disease with high-risk features. She presents to the medical oncologist today about 6 weeks from surgery and confirms she feels back to "normal" and is open to discussing adjuvant treatment. Which of the following is the most appropriate adjuvant therapy for LS's stage high-risk IIB colon cancer? A.Observation B.Capecitabine C.FOLFOX D.FOLFIRI

Correct answer is B. Patients with stage II disease with high-risk features are recommended to receive adjuvant chemotherapy with a single agent fluoropyrimidine. Patients with stage II disease with no high-risk features or with MSI-high disease would be eligible for observation.2 Answer A is incorrect because LS has stage II disease with high-risk features with no contraindications to chemotherapy. Answer C is not the most appropriate adjuvant therapy at this time, as oxaliplatin in addition to a fluoropyrimidine has not been shown to improve survival benefit for stage II patients. Furthermore, oxaliplatin may not provide the same benefit in adjuvant therapy for patients over 70 years of age. Answer D is incorrect as irinotecan-containing regimens have not been shown to provide survival benefit in the adjuvant setting for early stage disease

SK is a 64-year-old morbidly obese woman who presents to the emergency department complaining of one month of post-menopausal vaginal bleeding. Her last menstrual period was in 2005 and she has a history of estrogen therapy for 6 months in 1990s following heavy menstrual bleeding. She has never had children. The emergency department obtains a pelvic ultrasound which demonstrated endometrial thickening at 4.5 mm. She is referred to OB/GYN who performs a colposcopy with endometrial biopsies at 10 and 2 which reveal FIGO grade 1 endometrioid adenocarcinoma as well as cervical intraepithelial neoplasia grade 1 at 10. SK undergoes primary surgical management with a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and biopsies. Her final pathology reveals a grade 1 endometrioid adenocarcinoma of the endometrium with tumor diameter 2.6x2.1x1.1 cm, depth of invasion 1.1 cm, into a 1.7 cm myometrium (more than one-half invasion), negative cervix, adnexa, and pelvic washing. There is no lymphovascular space invasion and negative lymph nodes. What further therapy, if any, should SK receive? a. Paclitaxel 175 mg/m2 + carboplatin (AUC 6) every 21 days for 6-8 cycles b. Observation or vaginal brachytherapy c. Doxorubicin 45 mg/m2 + cisplatin 50 mg/m2 every 21 days for 6 cycles d. Tamoxifen 20 mg daily

Correct answer is B. SK has early stage IB, grade 1 endometrial cancer (tumor invades more than one-half the myometrium). Given her low-risk, early-stage disease, and no known adverse risk factors, observation or vaginal brachytherapy is recommended. Answer A, C and D are inappropriate as the patient has low-risk, early-stage disease and chemotherapy and anti-hormonal therapy would only be appropriate for advanced endometrial cancer.

RL is a 64-year-old female with metastatic, KRAS-wild-type colorectal cancer to her liver and lungs. She recently started FOLFOX + panitumumab and presents today for Cycle 3. She reports a new rash that is pruritic, occasionally weeps pus, and extends over her face and chest mainly, and partially covers her back. She states she has been compliant taking her doxycycline since she started treatment. What is the most appropriate intervention for RL's grade 2 papulopustular rash at this time? A. Continue panitumumab at same dose and change the doxycycline to minocycline B. Continue panitumumab at same dose and initiate topical hydrocortisone C. Dose reduce panitumumab and initiate topical salicylic acid D. Dose reduce panitumumab and initiate oral prednisone

Correct answer is B. Since RL's rash is categorized as a Grade 2 rash, the most appropriate therapy would be to continue panitumumab at the same dose and initiate therapy with topical steroids in addition to the oral tetracycline. Answer A is incorrect because there is currently no evidence minocycline is more effective than doxycycline for EGFR inhibitor-associated papulopustular rash. The panitumumab however can be continued at the same dose. Answer C is incorrect. Dose reduction would be appropriate for a grade 3 or 4 rash, however salicylic acid should never be used for EGFR inhibitor-associated papulopustular rash Answer D is incorrect. This intervention would be appropriate for a grade 3 or 4 rash

TS is a 36-year-old premenopausal white female who presents with a diagnosis of lobular carcinoma in situ (LCIS). She has a significant family history of breast cancer including her mother, maternal grandmother, and maternal aunt who were all diagnosed prior to 60 years of age. TS had one child at age 31 and no history of oral contraceptive use or estrogen replacement therapy. She was 12 years old at first menarche. What are TS's risk factors for the development of invasive ductal carcinoma? A.Premenopausal status, family history, race, and LCIS B.LCIS, family history, early age of menarche, age > 30 at birth of first child C.Family history, race, early age of menarche, age > 30 at birth of first child D.Premenopausal status, age, LCIS, and < 3 pregnancies

Correct answer is B. TS is at an increased risk for developing invasive breast cancer due to her LCIS, significant family history, early age of menarche, and age > 30 at birth of her first child. Answer A is incorrect because premenopausal status and race are not risk factors. Answer C is incorrect because race is not a risk factor. Answer D is incorrect because her age, premenopausal status, and number of pregnancies (other than nulliparity) are not risk factors.

BZ is a 50-year-old postmenopausal woman who presents with jaundice, dyspnea on exertion, and fatigue. Workup reveals a left breast cancer that has metastasized to the liver and lung, which is the cause of her symptoms. The pathology is ER=0%, PR=0%, HER2-negative, PD-L1 negative, and germline BRCA1/2 positive. Which of the following first-line regimens is the most appropriate for BZ at this time? A. Rucaparib B. Talazoparib C. Gemcitabine D. Docetaxel

Correct answer is B. Talazoparib. The EMBRACA trial, which compared talazoparib was physician's choice of chemotherapy for patients with germline BRCA1/2 mutation, found an improved median PFS and response rate in the talazoparib group. As a result, olaparib or talazoparib are preferred treatment options for patients with germline BRCA1/2 mutations in the NCCN Guidelines®. Answer A is incorrect because the PARP inhibitor rucaparib has not been adequately studied for use in breast cancer at this time. Answer C and D are incorrect because the PARP inhibitors olaparib and talazoparib have shown an improved median PFS and response rate compared to chemotherapy. Chemotherapy, such as gemcitabine or docetaxel, could be considered for this patient as second-line therapy after a PARP inhibitor.

EH is a 65-year old male who presents to his PCP with complaints of bleeding with bowel movements. A colonoscopy demonstrated an obstructing and circumferential mass 10 to 12 cm from the dentate line. CT abdomen/pelvis revealed bilobular liver lesions. Biopsy of a liver lesion displayed moderately differentiated adenocarcinoma consistent with colorectal primary. The tissue was sent for next generation sequencing which showed KRAS G12C and TP53 Y107* mutations, microsatellite status stable, and tumor mutational burden of 8 mutations/megabase. He presents to the medical oncologist today to discuss systemic therapy. His ECOG performance status is 1 and he has controlled hypertension on amlodipine. Which of the following is the most appropriate initial therapy for EH's metastatic colorectal cancer? A. Capecitabine B. FOLFOX + cetuximab C. FOLFIRI + bevacizumab D. FOLFOXIRI + panitumumab

Correct answer is C. FOLFIRI ± bevacizumab is an acceptable option for first-line treatment of metastatic colorectal cancer in patients who are eligible to receive intensive therapy. Controlled hypertension is not a contraindication to receive bevacizumab. Answers B and D are incorrect because EH has a KRAS G12C activating mutation, which confers resistance to EGFR monoclonal antibodies. In addition, FOLFOXIRI only has support in combination with bevacizumab, not an EGFR monoclonal antibody. Answer A is not the most appropriate at this time. If EH was not eligible for intensive therapy, single agent capecitabine would be an appropriate choice.

Correct answer is C. Given the local metastatic disease, the therapy of choice would be primary chemoradiation. Therefore, the treatment will include external beam whole pelvic radiation therapy plus chemosensitization with weekly cisplatin 40 mg/m2 IV followed by high-dose rate brachytherapy. Answer A is not the most appropriate treatment option as DD has stage IVA disease and therefore is not a surgical candidate. Answers B and D as single modality therapy would not be the most appropriate treatment options as multiple trials have demonstrated the risk of death from cervical cancer is decreased by 30% to 50% by the addition of concurrent cisplatin to pelvic radiation

FT is a 55-year-old female with a newly diagnosed metastatic intestinal type gastroesophageal junction cancer. Her oncologist recommends starting first-line chemotherapy with cisplatin and capecitabine. Given the location and histology of the tumor, she may be eligible to receive targeted therapy in addition to the chemotherapy. Screening for which of the following tumor markers should be performed in consideration of targeted therapy? A. KRAS activating mutation B. BRAF V600E mutation C. HER2 expression D. ALK fusion

Correct answer is C. HER2 overexpression occurs in 20-30% of patients with gastric cancer and has been shown to occur more frequently in tumors located in the gastroesophageal junction compared to the stomach. NCCN recommends the addition of trastuzumab to chemotherapy for HER2 positive disease for first-line treatment. Answer A is incorrect because unlike metastatic colon and rectal cancers, EGFR inhibitors like cetuximab and panitumumab have not been shown to be effective in the treatment of gastric and esophageal cancers and downstream targeting of KRAS has not yet shown to be effective outside of early phase clinical trials with novel agents. Therefore, testing this patient's tumor for a KRAS mutation would not provide benefit for additional therapies. Answers B & D are not correct because BRAF mutations and ALK alterations are very rare in gastric and esophageal cancers. BRAF inhibitors with or without MEK inhibitors and ALK inhibitors have not been thoroughly studied in these patients, therefore there are no approved therapies for a gastric or esophageal patient with a BRAF or ALK alteration.

JP is a 53-year-old male who presents to his physician because he has been experiencing night sweats that wake him up and is feeling more tired. He has a history of hepatitis B infection. His physician performs diagnostic testing and an alpha fetoprotein (AFP) level is 1,405 ng/mL. A CT scan of the abdomen and pelvis reveals a liver mass involving the right lobe of the liver measuring 5.5 x 5.3 cm and is consistent with a locally advanced, unresectable HCC. He is Child-Pugh class A6. Which treatment option will offer JP the best overall survival for his unresectable HCC? 1. Liver transplantation 2. FOLFOX 3. Atezolizumab + bevacizumab 4. Sorafenib

Correct answer is C. In the IMbrave 150 trial, atezolizumab + bevacizumab was compared against sorafenib in previously untreated patients with unresectable HCC. Median OS had not been reached in the combination group, vs only 13.2 months in the sorafenib group. The combination did significantly improve PFS as well. Answer A is incorrect because this patient's tumor is >5 cm so he is not eligible for liver transplantation Answer B is incorrect because cytotoxic chemotherapy has not been shown to improve OS in patients with HCC. FOLFOX is an option for patients with unresectable or metastatic HCC if they cannot otherwise tolerate a TKI or anti-angiogenic agent. Answer D is incorrect, although up until recently would have been the correct choice. But with the results of the IMbrave150 trial, atezolizumab + bevacizumab provides an OS survival advantage over sorafenib in the first-line setting for unresectable or metastatic HCC.

CH is a 46-year-old postmenopausal Caucasian woman who presents to the clinic with a newly diagnosed left breast cancer found on screening mammogram. The breast mass measured 1.2 x 2.1 cm and her axillary lymph nodes were negative by ultrasound. Core biopsy of the breast mass indicates an invasive ductal carcinoma, nuclear grade 1 (well differentiated), ER = 70%, PR = 0%, HER2 IHC = 2+, HER2 FISH negative. CH has stage IIA disease (T2, N0, M0) that is ER -positive, HER2-negative and well differentiated. She has several good prognostic features (ER/PR-positive, HER2-negative). The goal of therapy for CH is cure. She plans to undergo primary surgery. If she were to have a lumpectomy, lymphatic mapping with SLNB would be the most appropriate option. Radiation therapy would be required with a lumpectomy. If this patient underwent a mastectomy, post-mastectomy radiation would only be considered if she were to have positive lymph nodes or close or positive surgical margins. CH elected to have a lumpectomy with surgical axillary staging. She has negative axillary nodes. Her pathologic stage is IIA (pT2, pN0, M0). The Oncotype DX recurrence score on the surgical specimen is 11. What would be the most appropriate adjuvant endocrine therapy for CH if she were premenopausal? A. Anastrozole x 5 years B. Goserelin + anastrozole x 10 years C. Tamoxifen x 10 years D. Exemestane x 5 years

Correct answer is C. NCCN Guidelines® recommend tamoxifen 20 mg daily for 5 - 10 years. The combination of OAS + tamoxifen or OAS + AI should be considered for women at higher risk of recurrence (i.e. young age, high-grade tumor, LN involvement). If at the completion of 5 years of tamoxifen, CH becomes postmenopausal, then she could consider an additional 5 years of therapy with an aromatase inhibitor or continue on tamoxifen for an additional 5 years. If after 5 years of therapy with tamoxifen, she remains premenopausal, then she could either discontinue adjuvant therapy or continue on tamoxifen for an additional 5 years. ASCO guidelines state that women should receive an additional 5 years of tamoxifen if they remain premenopausal or perimenopausal following the initial 5 years of tamoxifen (for a total duration of 10 years). Answer A is incorrect because single agent AI (anastrozole) is not recommended for premenopausal women. Answer B is incorrect because the combination of OAS + AI is only indicated for a duration of 5 years Answer D is incorrect because single agent AI (exemestane) is not recommended for premenopausal women.

SK is a 64 yo F w FIGO grade 1 endometrioid adenocarcinoma as well as cervical intraepithelial neoplasia grade 1 at 10. SK undergoes primary surgical management with a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and biopsies. SK has been appropriately undergoing active surveillance with visits every three to six months for the past 2 years. She is generally feeling well, but she does report intermittent bleeding. Upon further work-up SK is found to have local recurrence confined to the vagina. Which of the following is the most appropriate treatment for SK at this time? a. Surgical resection and intraoperative radiation therapy b. Chemotherapy c. Pelvic EBRT and brachytherapy d. Hormone therapy

Correct answer is C. SK has local recurrence confined to the vagina. Since she has not had prior radiation or brachytherapy to the site of recurrence, SK is eligible for pelvic EBRT plus brachytherapy or surgical exploration + resection. Isolated vaginal recurrences treated with radiation therapy alone have good local control with 5-year survival rates of 50 to 70%. Answer A would not be most appropriate as intraoperative radiation therapy is a NCCN Guidelines® category 3 recommendation. Answer B and D would not be appropriate as chemotherapy and hormone therapy are considered for patients with local recurrence who have previously undergone previous external beam radiation therapy.

KW is a 56-year-old female who presents to the emergency room with syncope and hematemesis. She underwent an endoscopy (EGD) which showed an ulcerated mass in the antrum of the stomach. Pathology from the biopsy was consistent with poorly differentiated adenocarcinoma, diffuse type with signet ring cells. PET scan was negative for metastases. An exploratory laparotomy did not show any peritoneal disease. After discussion with a multi-disciplinary team, KW will undergo perioperative chemotherapy with surgery. Which of the following perioperative regimens is most appropriate for KW's localized gastric cancer? A. EOX (epirubicin, oxaliplatin, capecitabine) B. 5-FU + oxaliplatin + radiation C. FLOT (5-FU, leucovorin, oxaliplatin, docetaxel) D. Carboplatin + paclitaxel + radiation

Correct answer is C. The FLOT4-AIO trial showed significant improvement in overall survival with perioperative FLOT over the ECF/ECX regimen. FLOT has now replaced ECF and its modifications as the category 1 perioperative regimen for localized gastric cancer.1 Answer A is not most appropriate due to the removal of ECF and its modifications, including EOX, from the perioperative regimen recommendations. Answers B and D are not appropriate perioperative regimens for localized gastric cancer due to the inclusion of radiation. These regimens would be more appropriate for preoperative or definitive treatment of localized or locally advanced esophageal cancer, respectively.

YC is a 37-year-old premenopausal African American woman who presents to her medical oncologist with a newly diagnosed right breast cancer confirmed with ultrasound and core needle biopsy as invasive ductal carcinoma. The tumor is 1.3 cm x 1.3 cm (T1c,N0,M0; stage 1A), ER negative, PR negative, HER2 IHC 2+, FISH = negative (triple negative). Pathology also reveals a nuclear grade of 2 (moderately differentiated) and a Ki-67 of 50%. She recently underwent a modified radical mastectomy with negative LN and negative margins (>1 mm). She was found to have a BRCA2 mutation but otherwise has no other comorbidities. According to NCCN Guidelines®, which of the following adjuvant regimens would be the most appropriate for YC? A. Cyclophosphamide + methotrexate + fluorouracil (CMF) B. Carboplatin C. Dose dense doxorubicin + cyclophosphamide (AC) paclitaxel D. Olaparib

Correct answer is C. YC has a stage Ia (T1c,N0,M0) breast cancer. Given that her primary tumor was > 1 cm, adjuvant chemotherapy is routinely recommended following her modified radical mastectomy. There is not one standard recommended adjuvant regimen. YC and her oncologist have decided to proceed with dose dense doxorubicin + cyclophosphamide followed by paclitaxel (see table for additional appropriate regimens). She would not need radiation therapy since she was LN-negative, primary tumor was < 5 cm, and margins were > 1 mm. She also would not receive adjuvant endocrine therapy since she is ER- and PR-negative. Answer A is incorrect because cyclophosphamide, methotrexate, fluorouracil (CMF) is an option for adjuvant treatment but it is not listed as a preferred option by NCCN Guidelines®. Answer B is incorrect because single agent carboplatin is not a recommended option for adjuvant chemotherapy. It is a recommended option for the treatment of metastatic disease in patients with TNBC and BRCA1/2 mutation, such as YC. Answer D is incorrect because olaparib is not a recommended option for adjuvant treatment. It is recommended to treat metastatic breast cancer for patients with a BRCA1/2 mutation.

CA is a 65-year-old woman who noted intermittent difficulty with swallowing and voice hoarseness. A swallow study was negative, but a CT angiogram was performed and a 2.3 x 2 x 3.6 cm left thyroid mass was found. Biopsy confirmed differentiated thyroid carcinoma. A total thyroidectomy was performed and pathology confirmed papillary thyroid carcinoma (PTC). Six of 33 lymph nodes were positive in the left neck, and left tracheal resection showed papillary thyroid carcinoma. What is the most appropriate therapy for CA at this time? A. Observation B. Lenvatinib C. Radioactive iodine D. Dabrafenib/trametinib

Correct answer is C: Radioactive iodine (RAI) is preferred since there was gross extrathyroid extension (trachea). Lymph node involvement and primary tumor 2-4 cm are both additional factors that can increase the chance of RAI recommendation. Lenvatinib is approved for PTC after progression of RAI. Although BRAF mutations are common in PTC, we do not know the mutational status of this patient at this time.

JM is a 65-year-old male who underwent a Whipple procedure for resectable pancreatic cancer 10 weeks ago. He now presents to the medical oncologist to begin adjuvant therapy. He did not receive neoadjuvant therapy. He has recovered quite well from the surgery with an ECOG performance status of 0 and states that his goal is to return to golfing 2-3 times a week. Which of the following is the most appropriate adjuvant treatment for JM? A. Observation B. Gemcitabine C. Gemcitabine + nab-paclitaxel D. mFOLFIRINOX

Correct answer is D. Based on results from the PRODIGE 24 trial, both the NCCN Guidelines®148 and ASCO guidelines recommend mFOLFIRINOX as a preferred regimen for adjuvant treatment of resected pancreatic cancer for patients with good performance status Answer A is incorrect because observation has shown inferior results to chemotherapy in the adjuvant setting Answer B would be an option if JM was not able to tolerate mFOLFIRINOX or gemcitabine + capecitabine Answer C is incorrect because at this time there are insufficient data to recommended gemcitabine + nab-paclitaxel for adjuvant treatment

VT is a 58-year-old postmenopausal Caucasian woman who was diagnosed with stage IIIA (T2N2M0) invasive ductal carcinoma. Pathology revealed a tumor that is ER-negative, PR-negative, HER2-negative (triple negative). She was treated with neoadjuvant doxorubicin and cyclophosphamide (AC) every 2 weeks x 4 cycles followed by paclitaxel weekly x 12 cycles. Following neoadjuvant treatment, she underwent breast-conserving surgery. At the time of surgery, she is found to have residual disease in the breast. In addition to radiation, which adjuvant treatment is most appropriate for VT? A. Ado trastuzumab emtansine B. Docetaxel + cyclophosphamide C. Paclitaxel + carboplatin D. Capecitabine

Correct answer is D. Based on the results of the CREATE-X trial, DFS was improved in patients with HER2-negative breast cancer who had residual disease at the time of surgery following neoadjuvant chemotherapy. NCCN Guidelines® AND ASCO Guidelines recommend consideration of 6-8 cycles of adjuvant capecitabine in patients with triple-negative breast cancer and pathologic invasive residual disease following neoadjuvant treatment with taxane-, alkylator-, and anthracycline-based chemotherapy. Answer A is incorrect because ado trastuzumab emtansine is only appropriate as adjuvant treatment for patients with HER2-positive breast cancer and residual disease following neoadjuvant treatment. Answer B is incorrect because docetaxel and cyclophosphamide is an option in the adjuvant setting for patients who have not received neoadjuvant chemotherapy. Answer C is incorrect because paclitaxel and carboplatin is not recommended in the adjuvant setting.

GS is a 62-year-old female who presents with MBC to the bone. She was originally diagnosed with stage IIB ER-negative, PR-negative, HER2 positive (IHC 3+) breast cancer 10 years ago and received treatment with lumpectomy, adjuvant chemotherapy with TAC x 6 cycles, followed by radiation and 1 year of trastuzumab. She has mild bone pain that is controlled with an NSAID. Biopsy of her recurrent disease is consistent with the original tumor pathology. Which of the following regimens is the most appropriate option for GS at this time? A. Trastuzumab alone B. Pertuzumab + docetaxel C. Trastuzumab + lapatinib D. Trastuzumab + pertuzumab + docetaxel

Correct answer is D. GS should be started on chemotherapy and anti-HER2 therapy for her diagnosis of HR-negative, HER2-positive metastatic disease. She is initiated on the combination of docetaxel, pertuzumab, and trastuzumab every 3 weeks, which has a category 1 recommendation from NCCN®. Weekly paclitaxel in combination with every 3 week trastuzumab and pertuzumab is another appropriate option. This therapy would be continued until disease progression or intolerable adverse effects. Answer A is incorrect because chemotherapy should be given in addition to anti-HER2 therapy for patients with HR-negative, HER2-positive metastatic breast cancer. Answer B is incorrect because pertuzumab is only studied in combination with other anti-HER2 agents. Answer C is incorrect because chemotherapy should be given in addition to anti-HER2 therapy for patients with HR-negative, HER2-positive metastatic breast cancer.

FR is a 37-year-old premenopausal woman with a history of breast cancer. She was originally diagnosed four years ago with stage IIB (T2, N1, M0), ER/PR-positive, HER2-negative invasive ductal carcinoma. She underwent a modified radical mastectomy and adjuvant chemotherapy with dose dense AC followed by weekly paclitaxel. After completing chemotherapy, she initiated tamoxifen with a planned initial duration of 5 years. Now 2 years after starting tamoxifen, she presents to her oncologist with severe back pain x 3 weeks. A bone scan reveals multiple areas of increased uptake in her thoracic and lumbar spine. Biopsy of T3 confirms metastatic breast cancer that is now ER+, PR+, and HER2-positive (IHC 3+). CT of the chest/abdomen was negative for other sites of metastases. FR has bone-only metastases, her disease is now ER/PR positive, HER2-positive, and she is relatively asymptomatic (pain controlled with OTC analgesics). Given that she experienced disease progression while receiving endocrine therapy and there is a known survival benefit for chemotherapy + HER2-targeted therapy, her oncologist treated her with docetaxel, trastuzumab, and pertuzumab (THP) x 6 cycles with a good response. She is now planned to continue maintenance trastuzumab and pertuzumab and restart endocrine therapy. FR's estradiol and FSH levels are still in the premenopausal range. What is the most appropriate endocrine treatment for FR's metastatic disease? A. Continue tamoxifen B. Discontinue tamoxifen; start exemestane C. Continue tamoxifen; add fulvestrant D. Discontinue tamoxifen; start goserelin and anastrozole

Correct answer is D. Given that FR's breast cancer recurred while receiving tamoxifen and she is premenopausal, it would be appropriate to discontinue tamoxifen and initiate 2nd-line therapy with OAS and endocrine therapy as for postmenopausal women. FR will receive ovarian suppression with goserelin in combination with anastrozole. She should continue to receive endocrine therapies sequentially at time of disease progression unless her disease becomes endocrine-refractory, she progresses through endocrine options, or she develops symptomatic metastatic disease at which time chemotherapy would be indicated. FR is also prescribed trastuzumab every 3 weeks since her disease now HER2-positive. Answer A is incorrect because endocrine therapy should be modified since her disease has recurred on tamoxifen. Answer B is incorrect because she is premenopausal; therefore, she should be treated with an LHRH agonist in addition to an AI. Answer C is incorrect because the combination of fulvestrant and tamoxifen is not recommended by ASCO or NCCN Guidelines®.

SM has clinical stage IVB (pleural effusions and liver lesions) ovarian cancer and is deemed upon imaging and in consultation with surgery to be unlikely to be optimally cytoreduced. SM completed 3 cycles of neoadjuvant chemotherapy, underwent interval debulking surgery attaining optimal cytoreduction, and subsequently completed 3 more cycles of adjuvant chemotherapy with paclitaxel and carboplatin, achieving a complete response. SM presents to clinic 2 years after completing adjuvant chemotherapy which was complicated by grade 2 peripheral neuropathy. She has remained on niraparib maintenance but due to recent symptoms of abdominal distension, a CT scan was completed revealing new lymphadenopathy and confirmed disease recurrence. During SM's initial adjuvant chemotherapy with paclitaxel and carboplatin following interval debulking surgery, she experienced a severe hypersensitivity reaction on cycle 6 of carboplatin, characterized by cough and shortness of breath. Which of the following is the proper management of a severe platinum hypersensitivity reaction? A. Stop infusion, give corticosteroid, monitor for 30 minutes and resume at a slower rate B. Stop infusion, start oxygen and observe C. Administer IM epinephrine D. Stop infusion, start oxygen, administer H1 and H2 blocker and corticosteroid

Correct answer is D. Stopping the offending agent in any hypersensitivity reaction is the first step along with appropriate pharmacologic intervention which includes both H1 and H2 antagonists to stop the acute hypersensitivity reaction and steroid to prevent a delayed or rebound reaction. Answer A is not correct as steroids alone do not provide immediate benefit in management of an acute hypersensitivity reaction; rather corticosteroids prevent rebound or delayed reactions. Answer B is inappropriate as a pharmacologic intervention is needed to stop the hypersensitivity reaction. Answer C is missing the most important step of stopping the offending agent as well as providing oxygen. Additionally, this is not reported to be a life threatening or anaphylactic reaction and other interventions should be considered first.

GM is a 60-year-old male with metastatic esophageal squamous cell carcinoma. He has been receiving first-line chemotherapy with FOLFOX (5-FU, leucovorin, and oxaliplatin) for 10 cycles. GM has handled chemotherapy well. Recent CT scans of the chest and abdomen reveal that the primary tumor and liver metastases have increased in size. GM would like to continue to receive treatment. Next generation sequencing reveals microsatellite stable and PD-L1 combined positive score (CPS) of 2. Which of the following regimens is most appropriate for second-line treatment of GM's metastatic esophageal squamous cell carcinoma? A. ECF (epirubicin, cisplatin, 5-FU) B. Pembrolizumab C. Ramucirumab + paclitaxel D. Nivolumab

Correct answer is D. The ATTRACTION-3 trial showed significant OS improvement of nivolumab over chemotherapy in patients with unresectable or metastatic esophageal SCC who were refractory or intolerant to one previous fluoropyrimidine-based and platinum-based chemotherapy. Nivolumab has an FDA indication in this setting, as well as support from the NCCN Guidelines®. Answer A is incorrect because three-drug chemotherapy regimens are not used in the subsequent-line setting. Answer B is not appropriate at this time because pembrolizumab is indicated for second-line treatment in esophageal SCC only if the tumor is MSI-H or has a PD-L1 CPS ≥10. Answer C is incorrect because ramucirumab-based regimens are only indicated for adenocarcinoma histologies.

JG is a 33 year old female with Philadelphia chromosome negative pre B-cell ALL who has undergone multi-agent chemotherapy for remission induction treatment and unfortunately relapsed within 3 months of this treatment. JG is planned to receive blinatumomab for her relapsed ALL. She does not have central nervous system involvement and is found to have 68% blasts prior to therapy with blinatumomab. On day 2 of blinatumomab infusion, JG develops emesis with rigors, fever to 39 °C, and abnormal liver function tests. She is experiencing grade 1 cytokine release syndrome (CRS). Which of the following strategies should be employed to treat her CRS? A. Supportive care B. Stop blinatumomab C. Tocilizumab D. Dexamethasone

Correct answer= A: Per the NCCN guidelines and the American Society for Transplantation and Cellular Therapy, grade 1 CRS should be treated with supportive care only. B: Per the blincyto PI, grade 3+ CRS requires interrupting the blinatumomab infusion C: Per the NCCN guidelines and the American Society for Transplantation and Cellular Therapy, tocilizumab would be appropriate if JG had several days of grade 1 CRS or if the CRS escalated to 2+ D: Steroids would be appropriate, per the blincyto PI, if JG had grade 3+ CRS.

SB is a 28-year-old female with relapsed B-ALL who is undergoing treatment with tisagenlecleucel. Which of the following medications should SB initiate on the day of the CAR-T cell infusion? A. Corticosteroids B. Levofloxacin C. Levetiracetam D. Rasburicase

Correct answer= C (Levetiracetam). Tisagenlecleucel is associated with CRES/ICANS and therefore seizure prophylaxis is indicated for SB. Choice A is incorrect because corticosteroids are thought to reduce efficacy of cellular therapy and their routine use should be avoided. Choice B is not clearly indicated, some centers may choose to use antibacterial prophylaxis but this is not clearly indicated. Choice D is incorrect given the current amount of case information, since SB's risk for tumor lysis syndrome is not known and would be greater during conditioning in preparation for CAR-T cell infusion

AG is a 50-year-old gentleman with a new diagnosis of locally advanced squamous carcinoma of the tonsil. She received radiation and every3 week cisplatin. AG comes in for surveillance scans 12 months later and is found to have a new right lung lesion. Biopsy of the lesion proves recurrent SCC, and genetic testing reveals PD-L1 CPS of 50. What is the most appropriate therapy for AG at this time? A) Cetuximab/Fluorouracil/ Cisplatin B) Pembrolizumab/Fluorouracil/ Cisplatin C) Cisplatin/Paclitaxel D) Nivolumab

Pembrolizumab/Fluorouracil/Cisplatin (answer B) would be the most appropriate choice due to PD-L1 CPS of 50 based on the KEYNOTE-048 trial. Cetuximab plus chemotherapy is a category 1 recommendation, but KEYNOTE-048 had improved overall survival when PD-L1 CPS was greater than 20. Cisplatin/paclitaxel can be used if pembro or cetuximab + chemotherapy cannot. Nivolumab is approved for progression on or after platinum therapy, and it has been longer than 6 months since TG had platinum therapy (also as definitive treatment).

SD is a 26 yo M diagnosed with stage IIIA non-seminoma, good risk testicular cancer. He is scheduled to begin BEP for 3 cycles. He presents to clinic today for chemotherapy education. He has read that chemotherapy may cause neutropenia with fevers and is asking about filgrastim (G-CSF) use. Which of the following best explains the use of filgrastim with BEP? A) The use of G-CSF with bleomycin has been associated with an increased risk of bleomycin induced pulmonary toxicity in patients receiving BEP and is contraindicated. B) BEP is associated with a high (>20%) incidence of FN, so G-CSF for primary prophylaxis is recommended in all patients. C) Since SD has metastatic cancer, the goal of therapy is palliative, therefore G-CSF should only be used as secondary prophylaxis if SD develops FN during cycle 1 of BEP. D) G-CSF may increase one's risk of bleomycin induced pulmonary toxicity, but this risk is not proven and G-CSF may still be used when necessary in patients receiving BEP.

SD is diagnosed with stage IIIA non-seminoma, good risk testicular cancer. He is scheduled to begin BEP for 3 cycles. He presents to clinic today for chemotherapy education. He has read that chemotherapy may cause neutropenia with fevers and is asking about filgrastim (G-CSF) use. Which of the following best explains the use of filgrastim with BEP? A) The use of G-CSF with bleomycin has been associated with an increased risk of bleomycin induced pulmonary toxicity in patients receiving BEP and is contraindicated. B) BEP is associated with a high (>20%) incidence of FN, so G-CSF for primary prophylaxis is recommended in all patients. C) Since SD has metastatic cancer, the goal of therapy is palliative, therefore G-CSF should only be used as secondary prophylaxis if SD develops FN during cycle 1 of BEP. D) G-CSF may increase one's risk of bleomycin induced pulmonary toxicity, but this risk is not proven and G-CSF may still be used when necessary in patients receiving BEP.

AK is a 66-year-old man who comes into clinic for chemotherapy counseling. He will be starting cisplatin and radiation for locally advanced oropharyngeal cancer. He is a current smoker. What would you counsel him on regarding mucositis prevention? A) He will receive amifostine prior to each cisplatin, so he won't need to do anything at home B) He will need to swish and spit with doxepin solution before each radiation treatment C) He will need to swish and spit with a salt and soda solution D) He will receive dexamethasone swish and spit prior to each cisplatin, so he won't need to do anything at home

Salt and soda solution (answer C) is the only "suggested for use" option for PREVENTION of mucositis based on MASCC guidelines.

HN is a 62 yo M w extensive stage SCLC due to the presence extensive lymphadenopathy within the neck as well as innumerable liver metastasis. HN completed 4 cycles of chemoimmunotherapy ( Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV Days 1-3 and atezolizumab 1200 mg IV Day 1) and was restaged with a PET/CT which showed stable disease. He proceed with immunotherapy maintenance with atezolizumab every 21 days. 10 months into maintenance therapy, HN called the clinic complaining of increasing shortness of breath. CT confirms disease recurrence. Given disease progression after 10 months of therapy, what is the appropriate treatment regimen for HN? a. Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV days 1-3 every 21 days b. Irinotecan 60 mg/m2 IV Day 1, 8, 15 Q 21 days c. Cisplatin 30 mg/m2 IV Day 1, 8 and irinotecan 65 mg/m2 IV Day 1, 8 every 21 days d. Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV Days 1-3 and durvalumab 1500 mg IV Q21 days

The correct answer is A. Now HN has recurrent extensive stage SCLC with performance status of 0. He is to receive carboplatin AUC 5 IV day 1 and etoposide 100 mg/m2 IV days 1-3. Plan for 4 cycles, then reassess. A. He may be re-treated with a platinum agent and etoposide since 10 months had elapsed since his last chemotherapy, indicating his disease is platinum sensitive. Since HN progressed on maintenance atezolizumab therapy, he would not be eligible for additional immunotherapy. There is no data to support switching to an alternate immunotherapy at the point of recurrence on maintenance therapy with a different immunotherapy agent. Use of irinotecan or cisplatin/irinotecan is not the best answer as HN's recurrence was > 6 months from first-line therapy, it would be preferred to repeat that previous regimen.

LL is a 51 yo M w Workup revealed a 10cm tumor of the left kidney (clear cell histology) with regional lymph node involvement (Stage III). Following radical nephrectomy, LL chooses not to pursue adjuvant sunitinib. At his 2-year follow up, he is noted to have lymphadenopathy on his abdominal CT. A chest CT shows a 2 cm lung lesion. Biopsy of the lung lesion was consistent with metastatic clear cell renal cell carcinoma. At 2 years, he starts pazopanib and presents to his oncologist after 9 months of stable disease while on pazopanib. His treatment course thus far is notable for transaminitis, managed with pazopanib interruption and dose reduction. His ECOG performance status has declined from 0 to 1. His follow-up imaging reveals progressive disease with metastases to 2 bone sites. Which of the following is the most appropriate treatment at this time for LL? A) Cabozantinib B) Nivolumab + ipilimumab C) High dose interleukin-2 (HD IL-2) D) Everolimus

The correct answer is A. Cabozantinib and nivolumab are both NCCN guideline® category 1 recommendations for subsequent treatment of ccRCC as both has shown improved OS compared to everolimus in patients who progressed on prior TKI therapy. Nivolumab + ipilimumab has demonstrated impressive ORR and duration of response in this patient population, but this study was a Phase I trial. Thus, nivolumab + ipilimumab is an NCCN guideline category 2A recommendation. HD IL-2 is not an ideal option in LL as his performance status has declined since starting treatment.

AH is a 50-year-old postmenopausal female who is receiving adjuvant treatment with letrozole x 5 years for the treatment of an ER-positive, PR-positive, HER2-negative stage IA breast cancer. Her baseline dual-energy X-ray absorptiometry (DXA) scan reveals a T-score of -2.7. She is taking calcium 1,500 mg PO divided twice daily and vitamin D3 800 international units PO daily. In addition to encouraging physical activity and continued calcium and vitamin D supplementation, which of the following is the most appropriate action based on her DXA scan? A. Initiate denosumab every 6 months B. Observation C. Increase calcium and vitamin D supplementation D. Initiate zoledronic acid every 4 weeks ©2021 American Society of Health-System Pharmacists,

The correct answer is A. Initiate denosumab every 6 months. Given that AH has osteoporosis at baseline and is taking an AI (letrozole) which is well-known to cause bone loss, NCCN® task force and guidelines recommend initiating a bone modifying agent. Other acceptable options include zoledronic acid 4 mg every 6 months or zoledronic acid (Reclast®) 5 mg every year. Oral bisphosphonates could also be considered for this patient. A DXA scan should be repeated every 2 years. Answer B is incorrect because the patient is a candidate for a bone modifying agent (for reasons listed above). Answer C is incorrect because AH is already taking appropriate amounts of supplemental calcium and vitamin D. Answer D is incorrect because zoledronic acid is typically dosed every 6 months or annually for treatment of bone loss

HN is a 62 yo M w extensive stage SCLC due to the presence extensive lymphadenopathy within the neck as well as innumerable liver metastasis. HN completed 4 cycles of chemoimmunotherapy ( Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV Days 1-3 and atezolizumab 1200 mg IV Day 1) and was restaged with a PET/CT which showed stable disease. He proceed with immunotherapy maintenance with atezolizumab every 21 days. 10 months into maintenance therapy, he received Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV days 1-3 every 21 days. HN's CT scan after 4 cycles showed a partial response to therapy, and he elected to undergo active surveillance. He returns 1 month later after completing his fourth cycle of treatment with new complaints of cough, blood-tinged sputum, dyspnea, and chest pain. Upon work-up, it is determined that HN has disease progression within the chest and liver. His ECOG performance status remains 1-2. What is the most appropriate treatment option for HN's recurrent extensive stage SCLC? A. Lurbinectedin 3.2 mg/m2 IV Day 1 Q 21 days B. Carboplatin AUC 5 IV Day 1 and irinotecan 50 mg/m2 IV Days 1, 8, and 15 Q 21 days C. Etoposide 200 mg/m2 PO Days 1-3 Q 21 days D. Topotecan 1.5 mg/m2 PO Days 1-5 Q 21 days

The correct answer is A. Lurbinectidin is approved for relapsed/refractory SCLC. Topotecan, both oral and intravenous formulations, is recommended as an option for single agent therapy for relapsed disease that is platinum resistant, however the dose recommended in option D is for IV administration and not PO administration. Options B and C are incorrect as HN should not receive another platinum-based doublet as he has seen 2 cycles with platinum therapy and he is now has platinum resistant disease. Option C is incorrect and he has already received etoposide therapy twice and switching to a different active agent would be most appropriate. Plan for salvage therapy with lurbinectedin 3.2 mg/m2 IV day 1 every 21 days. Monitoring to include complete blood count checks prior to each cycle to ensure that HN has an ANC of greater than or equal to 1500/mm3 and platelets greater than or equal to 100,000/mm3. Additionally close monitoring of LFTs given the patients baseline liver disease in addition to recommended dose reductions associated with observed liver elevations while receiving lurbinectedin.

HZ is a 47-year-old postmenopausal female planned to receive docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) x 6 cycles followed by surgery for her diagnosis of HER2-positive, stage IIIB breast cancer. According to pertuzumab's prescribing information, what is an appropriate frequency for monitoring HF's LVEF during neoadjuvant therapy following baseline assessment? A. Every 12 weeks B. Every 6 months C. Every 6 weeks D. Every 2 months

The correct answer is A. Monitoring of LVEF with an ECHO or MUGA is recommended by pertuzumab's prescribing information at baseline and every 12 weeks during neoadjuvant treatment (at least once during neoadjuvant therapy).

HZ is a 47-year-old postmenopausal female who was diagnosed with ER-positive, PR-negative, HER2-negative stage 1A invasive ductal carcinoma 2 years ago. She was treated with a breast-conserving surgery followed by radiation and anastrozole. She presents to her medical oncologist for follow-up after 18 months of receiving anastrozole. She is noted to have new onset back and hip pain, which is due to metastatic breast cancer to the bone. The pathology of the metastatic site is also ER-positive, PR-negative, and HER2-negative. The tissue sample of the metastatic lesion is also found to be PIK3CA-mutated and BRCA-negative. HF is planned to receive docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) x 6 cycles followed by surgery for her diagnosis of HER2-positive, stage IIIB breast cancer. According to pertuzumab's prescribing information, what is an appropriate frequency for monitoring HF's LVEF during neoadjuvant therapy following baseline assessment? A. Every 12 weeks B. Every 6 months C. Every 6 weeks D. Every 2 months

SD, a 26-year-old male, presents to his primary care physician with painless swelling of his left testicle. After a two-week trial of antibiotics with no improvement in symptoms, the patient is referred to a urologist who confirms a solid testicular nodule on ultrasound. The patient then undergoes an inguinal orchiectomy, which reveals embryonal cell carcinoma. Staging CTs of the chest and abdomen reveal bulky retroperitoneal lymphadenopathy and pulmonary nodules. His alpha-fetoprotein is 500 ng/ml (normal range <10 ng/ml), beta-hCG is 3000 units/L (<5 units/L), and lactate dehydrogenase is 290 units/L (100 - 250 U/L). Based upon this information, what is SD's risk classification for his newly diagnosed nonseminoma? A) Good risk B) Intermediate risk C) Poor risk D) Unable to determine

The correct answer is A. SD has been diagnosed with embryonal cell testicular cancer which is a nonseminoma. He has a testicular primary with retroperitoneal lymphadenopathy and pulmonary metastases only. His HCG, AFP and LDH are 3000 U/Ll, 500ng/ml and 290 U/L, respectively. Therefore, SD is classified as good prognosis.

SD is a 26 yo M diagnosed with stage IIIA non-seminoma, good risk testicular cancer who completed 3 cycles of BEP and has no evidence of disease. He is now being followed by his oncologist for recurrence. Which of the following survivorship issues is SD at risk for? A) Secondary malignancies and cardiovascular disease B) Ocular toxicity and cardiovascular disease C) Ocular and dermatologic toxicity D) Pulmonary toxicity and hepatotoxicity

The correct answer is A. SD should be monitored for increased risk of secondary malignancies and cardiovascular disease as these long-term complications have been associated with premature mortality in testicular cancer survivors. Although pulmonary toxicity has been seen in testicular cancer survivors hepatotoxicity, ocular toxicity, stroke and dermatologic toxicity have not been associated as strongly with testicular cancer therapies.

MD is a 66-year-old retired schoolteacher, caring for her father with Alzheimer's disease. At her annual visit to her primary care provider, her provider discusses lung cancer screening options with MD. MD started smoking at age 14, and quit at age 64 when she moved her father into her home. She smoked approximately 1 pack per day. Is MD a candidate for lung cancer screening? A.Yes, she is a candidate for an annual chest X-ray B.Yes, she is a candidate for an annual chest CT C.No, she stopped smoking two years ago D.No, because she smoked < 2 packs per day

The correct answer is B. MD should be commended on her decision to stop smoking. The risk of lung cancer decreases over time after smoking cessation. MD is also a candidate for annual screening for lung cancer with CT based on the USPTF and NCCN© guideline criteria. She meets the inclusion criteria, similar to patients included in the NLST trial: her age is 66 years old and she has a 50 pack year smoking history. She does not have any unmanaged comorbid conditions and appears motivated to seek treatment. While screening will not help to prevent MD from developing lung cancer, it could reduce her risk of mortality due to the possibility of early detection of disease.

HF is a 61 yo white F w a newly diagnosed Stage IIIB (T4, N2, M0) left breast cancer that is ER 70%, PR 0%, and HER2 IHC 3+. After completion of neoadjuvant TCH + pertuzumab x 6 cycles, HF undergoes a lumpectomy. She is found to have residual disease at the time of surgery. HF will receive whole breast radiation and adjuvant HER2-directed therapy. She should also begin endocrine therapy with an AI following the completion of chemotherapy. Which of the following is the most appropriate adjuvant HER2-directed regimen for HF? A. Trastuzumab B. Ado-trastuzumab emtansine C. Trastuzumab + pertuzumab D. Neratinib

The correct answer is B. Ado-trastuzumab emtansine. Based on the results of the KATHERINE trial, invasive disease free survival is significantly improved with ado-trastuzumab emtansine x 14 cycles compared to trastuzumab x 14 cycles for patients with HER2-positive early stage breast cancer with residual disease following neoadjuvant chemotherapy. Answers A and C are incorrect because ado-trastuzumab emtansine would be preferred for patients with residual disease at the time of surgery, such as HF. Trastuzumab +/- pertuzumab could be considered for patients without residual disease. Answer D is incorrect because neratinib is only indicated in the adjuvant setting as extended adjuvant following 1 year of trastuzumab.

DS is a 60-year-old postmenopausal female who presents with metastatic breast cancer after a workup for back pain. She is found to have a 5 cm mass in her left breast and metastatic disease in her bones and lung. Pathology is consistent with ER=40%, PR=20%, and HER2 negative. DS is treated with palbociclib and letrozole for 15 months after which, a repeat CT scan reveals new liver metastases. DS is asymptomatic at this time. Additional biomarker testing does not reveal any actionable mutations. Which of the following is the most appropriate second-line treatment for DS? A. Abemaciclib + anastrozole B. Everolimus + exemestane C. Alpelisib + fulvestrant D. Ribociclib + tamoxifen

The correct answer is B. Everolimus and exemestane is a NCCN Guidelines® option for 2nd and subsequent line of therapy in the metastatic setting based on the results of the BOLERO-2 trial. Answer A is incorrect because there is limited data to support use of a CDK4/6 inhibitor (abemaciclib) in patients who progressed on a previous line of therapy including a CDK4/6 inhibitor (palbociclib). Answer C is incorrect because alpelisib is only indicated for patients that have a PIK3CA mutation; which DS does not have. Answer D is incorrect because there is limited data to support use of a CDK4/6 inhibitor (ribociclib) in patients who progressed on a previous line of therapy including a CDK4/6 inhibitor (palbociclib). Also, the combination of ribociclib and tamoxifen is not recommended due to risk of QTc prolongation.

HZ is a 47-year-old postmenopausal female planned to receive docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) x 6 cycles followed by surgery for her diagnosis of HER2-positive, stage IIIB breast cancer. What is the most appropriate recommendation if HF's LVEF decreased from a baseline of 55% to 40% via MUGA scan prior to cycle #6 of TCH-P (institutional lower limit of normal = 45%)? A. Continue trastuzumab and pertuzumab B. Hold trastuzumab and pertuzumab C. Restart trastuzumab but discontinue pertuzumab D. Restart pertuzumab but discontinue trastuzumab

The correct answer is B. It is recommended to hold trastuzumab and pertuzumab if the LVEF is < 50% with a fall of ≥ 10% points below pre-treatment value in patients receiving neoadjuvant or adjuvant treatment with trastuzumab and pertuzumab. This patient had an absolute decrease in 15% and an LVEF < 50%. Answer A, C, and D, are incorrect because this patient meets the criteria above to hold trastuzumab and pertuzumab.

SM has clinical stage IVB (pleural effusions and liver lesions) ovarian cancer and is deemed upon imaging and in consultation with surgery to be unlikely to be optimally cytoreduced. SM completed 3 cycles of neoadjuvant chemotherapy, underwent interval debulking surgery attaining optimal cytoreduction, and subsequently completed 3 more cycles of adjuvant chemotherapy with paclitaxel and carboplatin, achieving a complete response. SM presents to clinic 2 years after completing adjuvant chemotherapy which was complicated by grade 2 peripheral neuropathy. She has remained on niraparib maintenance but due to recent symptoms of abdominal distension, a CT scan was completed revealing new lymphadenopathy and confirmed disease recurrence. SM has now received 5 lines of chemotherapy, most recently topotecan monotherapy. She unfortunately complains of worsening abdominal pain and is confirmed to have progressive disease. She inquires about immunotherapy for treatment of ovarian cancer. Which of the following is true? A. Nivolumab is FDA approved for microsatellite instability-high (MSI-H) solid tumors B. Pembrolizumab is only appropriate if MSI-H or dMMR when there is no satisfactory alternative C. Pembrolizumab may be given as maintenance therapy following a PR/CR to platinum-based therapy for recurrent disease D. Checkpoint blockade may be given in platinum-sensitive relapse

The correct answer is B. Pembrolizumab should be reserved for treatment of relapsed ovarian cancer that is MSI-H or dMMR in which there are "no satisfactory alternatives". Answer A is incorrect as pembrolizumab is the only PD-1 inhibitor FDA approved for MSI-H solid tumors Answer C is incorrect as pembrolizumab is not appropriate for maintenance therapy. The recommended agents for maintenance following platinum-based therapy in recurrent disease are olaparib, rucaparib, and niraparib. Answer D is incorrect because patients with platinum-sensitive relapse should continue to receive platinum-based therapy as they are able. Platinum-sensitive relapse would not qualify as having "no satisfactory alternative".

LL is scheduled to begin therapy with pazopanib 800mg po daily. Throughout therapy with pazopanib, LL should be monitored for which of the following? A) Signs of depression B) Thyroid function C) Hyperlipidemia D) Hyperglycemia

The correct answer is B. Thyroid function is important monitoring parameter in patients receiving VEGF TKIs in general. Although the adverse effect profile is vast, the most likely adverse effect that LL will experience is decreased thyroid function which can occur in 4-8% of patients. Signs of depression, hyperlipidemia, hyperglycemia are all important monitoring parameters but are not part of the key adverse events associated with that VEGF TKIs. Mood disturbances, hyperlipidemia and hypokalemia were not reported.

YC is a 37-year-old premenopausal female who was diagnosed with triple negative stage IA breast cancer. She had a modified radical mastectomy and is planned to receive adjuvant treatment in 3 weeks with dose dense doxorubicin + cyclophosphamide (AC) x 4 cycles followed by weekly paclitaxel. She is interested in fertility preservation options. Based on the ASCO guideline on fertility preservation, which option is most appropriate for GK at this time? A. Ovarian transposition B. Embryo cryopreservation C. Ovarian tissue cryopreservation D. Leuprolide

The correct answer is B. YC should be referred to a fertility specialist as soon as possible (prior to the initiation of chemotherapy). According to the ASCO guideline, embryo cryopreservation and cryopreservation of unfertilized oocytes are considered viable options for this patient. Based on the results of the POEMS trial, the use of LHRH agonists, such as goserelin 3.6 mg SQ monthly starting 1 week prior to chemotherapy and continuing until the completion of chemotherapy, is an option for this patient; however, the ASCO guideline considers the use of LHRH agonists to be investigational Answer A is incorrect because ovarian transposition would only be recommended for patients undergoing irradiation as part of their cancer treatment. Answer C is not the most appropriate option because ovarian tissue cryopreservation is considered an investigational procedure at this time and therefore, should not be routinely recommended. Answer D is not the most appropriate answer because LHRH agonists are considered an investigational option according to the ASCO guidelines. Based on the recent results of the POEMS and PROMISE-GIM6 studies, this option could be considered in select patients; however, this is not currently supported by the ASCO or ASRM guidelines.

FS is a 48- year--old woman with complaints of a persistent dry cough that has not improved with antibiotics and cough suppressants. HPI: FS presented to her family practice physician 1 month ago with same complaints, treated for bronchitis with levofloxacin for 7 days. PMH: Hypothyroidism FH/SH: Smoked - 12 pack year history, quit 10 years ago. Social alcohol use. Drug History: NKDA, levothyroxine 88 mcg PO daily ECOG: 0 Laboratory: Serum creatinine (SCr) 0.55 Patient work-up: CXR: Left lower lobe mass CT scan - chest 1.4 cm x 2.2 cm left lower lobe density CT scan of abdomen, pelvis: negative Brain MRI: negative Bone scan: negative CT guided biopsy of left lower lobe lung nodule revealed poorly differentiated non-small cell carcinoma, adenocarcinoma histology. Tumor tissue was negative for any driver mutations. Staging: T1bN1M0 (one positive ipsilateral hilar lymph node); Stage IIA Treatment: Curative intent resection Based on the data, which adjuvant treatment regimen would be most appropriate for FS? a. Observation b. Pembrolizumab c. Cisplatin and pemetrexed d. Carboplatin and paclitaxel

The correct answer is C. Adjuvant chemotherapy for stage II should be cisplatin-based. A carboplatin-based doublet would be appropriate in the palliative setting or in patients that are unable to tolerate cisplatin. Option D is incorrect based on the use of carboplatin, rather than cisplatin. Option B is incorrect as immunotherapy in the setting of early stage disease is not recommended. Option A is also incorrect as observation is not supported by NCCN© guidelines given the stage of disease and the FS's performance status suggesting adjuvant chemotherapy would be appropriate.

VP is a 64-year-old female with HIV since 1996 on HAART therapy who presents with increasing discomfort with defecation over the past two months. A sigmoidoscopy demonstrated a firm, fixed obstructing rectal mass 3 cm from the anal verge. This was biopsied and found to be consistent with a squamous cell carcinoma. She has no evidence of metastatic disease. Which of the following treatment options is most appropriate for VP's localized anal cancer? A. Abdominoperineal resection with permanent colostomy B. Radiation alone C. Chemoradiation with 5-FU and mitomycin D. Chemoradiation with 5-FU and cisplatin

The correct answer is C. Chemoradiation with 5-FU and mitomycin (or capecitabine in place of 5-FU) is the preferred first-line treatment for localized anal cancer Answer A is not appropriate because APR is not recommended for first-line therapy of anal cancer due to long-term morbidity complications and high local recurrence rates Answer B is not appropriate because the addition of chemotherapy to radiation has been shown to improve complete remission rates, reduce locoregional recurrence, and decrease risk of having a colostomy compared to radiation alone Answer D is not appropriate because chemoradiation with 5-FU and cisplatin has been shown to have non-superior outcomes and increased colostomies compared to 5-FU and mitomycin. In addition, it is only a Category 2B recommendation from NCCN®.192

TS w metastatic pancreatic cancer received 6 cycles of gemcitabine + nab-paclitaxel, complicated by grade 2 neuropathy. He returns today to review a recent CT scan. Unfortunately, his CT of the chest shows new lung lesions and CT of the abdomen shows enlarged liver lesions. All labs are within normal limits, and his ECOG is now 1. What would be most appropriate subsequent therapy for TS? A. Capecitabine B. 5-FU + radiation C. Pembrolizumab D. Best supportive ca

The correct answer is C. Pembrolizumab is appropriate for MSI-H patients in subsequent-line therapy. 5-FU/leucovorin + liposomal irinotecan is another acceptable option for second-line chemotherapy for metastatic pancreatic cancer previously treated with gemcitabine-based chemotherapy. Answer A would be considered if TS had a poor performance status Answer B is incorrect due to TS's extra-pancreatic sites of disease. Radiation could be considered for TS if he was experiencing pain or obstruction from his tumor. Answer D would not be considered at this time due to TS's good performance status and ability to receive further treatment

SM presents for a pelvic ultrasound that confirms a left adnexa mass 3 x 2.6 x 2.3cm and subsequent biopsy reveals high-grade serous carcinoma. Additional staging confirms SM has clinical stage IVB (pleural effusions and liver lesions) ovarian cancer and is deemed upon imaging and in consultation with surgery to be unlikely to be optimally cytoreduced. Which of the following is the most appropriate initial therapy for SM? a. Staging TAH/BSO followed by adjuvant chemotherapy b. IP/IV carboplatin + paclitaxel followed by interval debulking surgery c. Dose-dense paclitaxel IV + carboplatin IV followed by interval debulking surgery d. Carboplatin + gemcitabine + bevacizumab

The correct answer is C. SM has stage IVB ovarian cancer and was unfortunately deemed to be unlikely to attain optimal cytoreduction. Neoadjuvant chemotherapy followed by interval debulking surgery is most appropriate. Answer A is not appropriate as patients who are unfit for surgery or unlikely to be optimally debulked should be considered for neoadjuvant chemotherapy prior to surgical cytoreduction. Answer B is not appropriate as intraperitoneal therapy should not be used as neoadjuvant treatment; these therapies may, however, be used following interval debulking surgery. Answer D is not appropriate as carboplatin + gemcitabine + bevacizumab is a preferred regimen in the setting of platinum-sensitive recurrence but not frontline therapy.

JJ is a 57-year-old female who presented to the emergency department with 17 days of abdominal distention and 3 days of abdominal pain. Physical exam revealed a mass in her right lower abdomen. Laboratory results were notable for Hgb 7.1 g/dL and CA-125 of 212 U/mL. Ultrasound confirmed the mass and imaging ruled out distant metastases. The patient is clinically staged with IB, high-grade serous ovarian cancer and underwent adequate surgical cytoreduction and staging. Which of the following is the most appropriate management for JJ at this time? a. Carboplatin/paclitaxel for 3 cycles b. Observation c. Carboplatin/paclitaxel for 6 cycles d. Carboplatin/paclitaxel/bevacizumab for 6 cycles

The correct answer is C. Six cycles of platinum-based combination chemotherapy are recommended as adjuvant therapy for patients with early stage, high-grade serous ovarian cancer. Answer A is incorrect based on the subgroup analysis of GOG-157 exhibiting favorable recurrence free survival with six over three cycles for high-grade serous histology. Answer B is incorrect because observation is only appropriate for stage IA/IB, low-grade serous or grade 1 of other histology. Answer D is incorrect because bevacizumab-based combination therapies are not currently recommended for stage I disease; these may be utilized for stage II-IV disease.

TS is a 60-year-old male who presented to his primary care physician with painless jaundice. Further workup reveals a mass in the pancreatic head compressing the bile ducts, resulting in a total bilirubin of 7.4 mg/dL. A CT of his chest, abdomen, and pelvis reveals suspicious lesions in his liver, which are found to be adenocarcinoma, consistent with a pancreatic primary. After placement of a biliary stent, he is referred to a medical oncologist. Today his bilirubin is 1.6 mg/dL and he states he currently walks 2 miles a day to and from the local park where he plays with his dog. TS states he "wants to fight this cancer" for his family. His ECOG performance status is 0. In addition, molecular work up of his biopsy reveals a mutation in KRAS and high microsatellite instability. Which of the following is the most appropriate initial treatment for TS's metastatic pancreatic cancer? A. Gemcitabine B. Gemcitabine + erlotinib C. Gemcitabine + nab-paclitaxel D. Pembrolizumab

The correct answer is C. TS has a PS ECOG score of 0, no pertinent comorbidities, minimal symptoms, good family support, and his goal is to treat; therefore, he is a good candidate for aggressive chemotherapy with gemcitabine + nab-paclitaxel or FOLFIRINOX Answer A is not appropriate because TS is eligible and willing to receive more aggressive chemotherapy. Gemcitabine alone would be appropriate if his ECOG PS was 2-3. Answer B is not the most appropriate option because gemcitabine + erlotinib is not considered a preferred regimen by NCCN Guidelines® despite a category 1 recommendation.148 Answer D is not the most appropriate option because although TS's tumor is MSI-H, pembrolizumab is not indicated in the first-line setting for a patient with good performance status.

FR is a 37-year-old premenopausal woman who is receiving endocrine therapy for newly diagnosed bone metastases. Since FR has metastatic breast cancer to the bone, the addition of a supportive therapy for bone metastasis would also be discussed with the patient. Her CrCl is within normal limits. According to ASCO and NCCN Guidelines®, which of the following is the most appropriate regimen to prevent skeletal-related events (SREs)? A. Denosumab 60 mg SQ every 6 months B. Pamidronate 90 mg IV every 6 months C. Zoledronic acid 4 mg IV every 12 weeks D. Denosumab 120 mg SQ every 12 weeks

The correct answer is C. Zoledronic acid 4 mg IV every 12 weeks. Answer A is incorrect because denosumab 60 mg SQ every 6 months is indicated for osteopenia and osteoporosis and would not be appropriate for a patient with bone metastases. Answer B is incorrect because pamidronate should be given every 3 - 4 weeks. Answer D is incorrect because denosumab should be given every 4 weeks. Baseline renal function should be evaluated for all BMAs and prior to each dose of bisphosphonates. Serum calcium, electrolytes, phosphate, magnesium, and hematocrit/hemoglobin should be monitored regularly with bisphosphonates. She would continue on a BMA for at least 2 years, or until there is a significant deterioration in her performance status.

CT is a 71-year-old man who presented to his primary care doctor with complaints of hematuria and urinary urgency. He was referred to a urologist for cystoscopy, which revealed a lesion in the bladder. Subsequently, he underwent a TURBT (transurethral resection of the bladder tumor) followed by single-dose intravesical chemotherapy. Pathology revealed Tis (in situ), non-muscle invasive urothelial carcinoma (UC). CT did well with maintenance BCG, however he later developed gross hematuria. Repeat TURBT revealed muscle-invasive urothelial carcinoma and staging subsequently showed pelvic metastases. Further pathologic analysis revealed PD-L1 tumor infiltrating immune cells covering 2% of the tumor area. His performance status and renal function continue to be excellent. Which therapy would be most appropriate at this time? A) Atezolizumab B) Nivolumab C) Gemcitabine/carboplatin D) Dose-dense MVAC

The correct answer is D. CT now has metastatic disease and is a candidate for cisplatin-based chemotherapy. Either ddMVAC or gemcitabine/cisplatin would be acceptable 1st-line options. Carboplatin should not be used in place of cisplatin given his good performance status and renal function. Atezolizumab in the first-line setting is only recommended for patients with >5% tumor infiltrating immune cells and who are cisplatin-ineligible. Nivolumab and other immune checkpoint inhibitors would be reasonable options after failure platinum-based therapy.

HN is a 62-year-old man in the emergency room. HPI: HN's family brings him to the ED because he is disoriented. His family reports he received azithromycin for bronchitis 2 weeks ago, hasn't been eating, and has experienced a 15-pound weight loss in the last 3 weeks. PMH: Hypertension FH/SH: Smoked two packs and a day for 25 years, quit 7 years ago. Social alcohol use. Physical Exam: ECOG performance status 1 Normal except for: General: Confused Neck: Extensive lymphadenopathy Lung: Normal respiratory effort, speaking in full sentences. (+) Rhonchi with expiratory wheezes. Neuro: Alert and oriented x 1, gait is unstable Laboratory: Na 126 Cl 104 WBC 6.5 K 4.6 BUN 18 ANC 3.4 SCr 0.86 Bilirubin 1.2 Platelets 238 ALT 68 AST 45 CT further reveals 4.3 x 3.2 x 4.6 cm right lower lobe mass, extensive lymphadenopathy throughout the neck and chest as well as innumerable liver metastasis. He undergoes a MRI which is negative. Based on the CT findings, on CT a lung biopsy was performed and pathology results were conclusive for SCLC. He has extensive stage SCLC due to the presence extensive lymphadenopathy within the neck as well as innumerable liver metastasis. Which treatment option is most appropriate for HN at this time? a. Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV Days 1-3 Q 21 days x 4-6 cycles b. Carboplatin AUC 5 IV Day 1, etoposide 100 mg/m2 IV Days 1-3 and durvalumab 1500 mg IV Day 1 Q 28 days x 4 cycles followed by durvalumab 1500 mg IV Day 1 Q 28 days c. Cisplatin 75 mg/m2 IV Day 1 and etoposide 120 mg/m2 IV Days 1-3 Q 21 days x 4 cycles with radiation (70 Gy) d. Carboplatin AUC 5 IV Day 1 and etoposide 100 mg/m2 IV Days 1-3 and atezolizumab 1200 mg IV Day 1 Q 21 days x 4 cycles followed by atezolizumab 1200 mg IV Day 1 Q 21 days

The correct answer is D. HN does not have limited stage SCLC, where concurrent chemotherapy with radiation therapy would be the treatment of choice, so option C is incorrect. He should receive chemotherapy with immunotherapy followed by immunotherapy maintenance because this is considered to be a category 1, preferred regimen in the NCCN Guidelines®, making options A incorrect Option B contains combination chemotherapy with immunotherapy, however the dosing schedule is incorrect for the combination with chemotherapy and should be every 21 days followed by durvalumab 1500 mg IV day 1 every 28 days.

LL. is a 51-year-old man who was referred to urology after presenting to his PCP with several months of intermittent hematuria. His past medical history is significant only for hypertension (controlled with amlodipine). Workup revealed a 10cm tumor of the left kidney (clear cell histology) with regional lymph node involvement (Stage III). Following radical nephrectomy, he asks if adjuvant sunitinib would benefit him. What is the most accurate response regarding the benefit of adjuvant sunitinib in L.L.? A) LL is likely to see his cancer recur just as quickly with adjuvant sunitinib as with no adjuvant treatment. B) LL may benefit from sunitinib, but it would likely be too toxic given his comorbid hypertension. C) LL is not a candidate for adjuvant sunitinib since he is not high risk for recurrence. D) LL is unlikely to derive any overall survival benefit from adjuvant sunitinib.

The correct answer is D. LL has a high risk of disease recurrence with Stage III RCC, and thus adjuvant sunitinib is an FDA-approved option. However, it has only been shown to improve disease-free survival (DFS) and not overall survival (OS). While one would expect his blood pressure to increase while on sunitinib, it is currently controlled on a single medication. Thus, his hypertension would not preclude use of sunitinib.

answer A. CT should receive at least one induction course of weekly intravesical BCG (answer A). If he responds, he may receive an additional induction course or subsequent maintenance BCG with repeat cystoscopy every 3-6 months for 2 years. Mitomycin is inferior to BCG in Tis disease, but may be utilized if patient is unable to tolerate BCG. Systemic chemotherapy is only indicated in muscle-invasive disease. Observation is not the best option as Tis has a high recurrence rate.

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