Lung

Front 1

Historically, what percentage of newly diagnosed lung cancer is small-cell type? A. 20 % B. 30 % C. 40 % D. 50 %

Back 1

The correct answer is A. Historically, 20 % of newly diagnosed lung cancers were reported as small cell in histology. Of those that present with small-cell lung cancer, approximately 30 % present with limited-stage disease. A recent publication suggests that the incidence of small-cell lung cancer is declining and accounted for 10 and 11 % (male and female, respectively) of lung cancer cases ( n = 237,792) in England between 1970 and 2007.

Front 2

Non-small-cell lung cancer most commonly presents at which stage? A. I B. II C. III D. IV

Back 2

The correct answer is D. Non-small-cell lung cancer most commonly presents at stage IV. A rough estimate of the percentage of presentation of each stage: I (10 %), II (20 %), III (30 %), and IV (40 %).

Front 3

What molecular abnormality is NOT seen in small-cell lung cancer? A. MYC amplifi cation B. EGFR expression C. TP53 mutation D. RB1 deletion

Back 3

The correct answer is B. Of the listed molecular abnormalities, EGFR expression has NOT been reported in small-cell lung cancers (SCLC). TP53 mutation is seen in over 80 % SCLC, RB1 deletion is seen in 90 %, and MYC amplification has been seen in 30 % of SCLC. MYC amplification has been associated with more recurrent, aggressive, and variant histologies of SCLC.

Front 4

Which of the following types of lung cancer is LEAST likely to metastasize to the brain? A. Adenocarcinoma B. Large-cell carcinoma C. Small-cell lung cancer D. Squamous cell carcinoma

Back 4

The correct answer is D. Of the listed histologies, squamous cell lung cancer is the least likely to metastasize to the brain. Adenocarcinoma, small cell, and large cell frequently metastasize to the brain.

Front 5

Which of the following paraneoplastic syndromes associated with small-cell lung cancer is not correctable with therapy? A. SIADH B. Lambert-Eaton syndrome C. Atrial natriuretic peptide syndrome D. Cerebellar degeneration syndrome

Back 5

The correct answer is D. Of all the listed paraneoplastic syndromes, cerebellar degeneration syndrome is not correctable with therapy. SIADH results from the excessive secretion of ADH, leading to hyponatremia and hypoosmolality. It improves with treatment of the underlying SCLC. Atrial natriuretic peptide (ANP) is a less common endocrinologic syndrome that can produce hyponatremia, natriuresis, and hypotension. It occurs in 15 % of SCLC and responds to therapy. Lambert-Eaton is a neurologic syndrome with symptoms similar to those of myasthenia gravis, though it improves with repetition (MG worsens with repetition). This condition also improves with treatment of the underlying malignancy.

Front 6

All of the following are true regarding Lambert-Eaton syndrome except: A. Symptoms improve with repetition. B. It is a paraneoplastic syndrome associated with small-cell lung cancer. C. It results from anti-calcium channel antibodies of the presynaptic receptor. D. Symptoms are not improved with anti-myasthenia therapies.

Back 6

The correct answer is D. Lambert-Eaton is a paraneoplastic syndrome of small cell lung cancer with symptoms that resemble myasthenia gravis. Whereas post synaptic receptor anti-calcium channel antibodies are involved in myasthenia gravis, the pre synaptic receptor antibodies are involved in Lambert-Eaton. Another important difference is that symptoms improve with repetition in Lambert-Eaton, but worsen with repetition in myasthenia gravis. While treatment of the underlying disease is most effective in improving symptoms, these also do respond to anti-myasthenic therapies.

Front 7

Which of the following is a paraneoplastic syndrome most commonly associated with squamous cell carcinoma? A. Hypercalcemia B. Hyponatremia C. Hypertrophic pulmonary osteoarthropathy D. Gynecomastia

Back 7

The correct answer is A. Of the listed paraneoplastic syndromes, hypercalcemia is most commonly associated with squamous cell carcinoma. Hyponatremia is most commonly associated with small-cell carcinoma. Hypertrophic pulmonary osteoarthropathy is most commonly associated with adenocarcinoma. Gynecomastia is most commonly associated with large-cell carcinoma.

Front 8

Which of the following is a paraneoplastic syndrome most commonly associated with adenocarcinoma? A. Hypercalcemia B. Hyponatremia C. Hypertrophic pulmonary osteoarthropathy D. Gynecomastia

Back 8

The correct answer is C. Of the listed paraneoplastic syndromes, hypertrophic pulmonary osteoarthropathy is most commonly associated with adenocarcinoma. Hypercalcemia is most commonly associated with squamous cell carcinoma. Hyponatremia is most commonly associated with small-cell carcinoma. Gynecomastia is most commonly associated with large-cell carcinoma.

Front 9

Which of the following is a paraneoplastic syndrome most commonly associated with large-cell carcinoma? A. Hypercalcemia B. Hyponatremia C. Hypertrophic pulmonary osteoarthropathy D. Gynecomastia

Back 9

The correct answer is D. Of the listed paraneoplastic syndromes, gynecomastia is most commonly associated with large-cell carcinoma. Hypertrophic pulmonary osteoarthropathy is most commonly associated with adenocarcinoma. Hypercalcemia is most commonly associated with squamous cell carcinoma. Hyponatremia is most commonly associated with small-cell carcinoma.

Front 10

All of the following statements regarding carcinoid tumors of the lung are true except: A. This is not the most common site of carcinoid tumors. B. The majority of these tumors are associated with carcinoid syndrome at presentation. C. The majority of these tumors are typical rather than atypical carcinoid tumors. D. In the lung, carcinoid tumors are primarily endobronchial, rather than parenchymal.

Back 10

The correct answer is B. Carcinoid tumors are rare in the lung, with the most common site of presentation in the GI tract. Within the lung, carcinoid tumors tend to be typical in histology and endobronchial. While the minority (10- 15 %) of typical carcinoid tumors present with carcinoid syndrome (flushing, diarrhea, wheezing), most eventually develop these symptoms.

Front 11

Which immunostain would most likely be negative in small-cell lung cancer? A. Chromogranin B. Synaptophysin C. CDX-2 D. TTF-1

Back 11

The correct answer is C. Of the listed immunostains, CDX-2 would most likely be negative, as it is a stain for gastrointestinal malignancy. TTF-1 stains are common in lung neoplasms and in 90 % of SCLC. Chromogranin and synaptophysin are neuroendocrine stains frequently seen in small-cell lung cancer.

Front 12

Which of the following statements regarding small-cell lung cancer is incorrect? A. Two-thirds of patients present with extensive-stage disease. B. Approximately 10 % present with superior vena cava syndrome. C. Approximately 10-20 % present with brain metastases at diagnosis. D. Median survival of limited-stage disease with chemotherapy with or without radiation is 7-11 months.

Back 12

The correct answer is D. Small-cell lung cancer presents predominantly with extensive-stage disease (2/3). While this is the most common histology to present with superior vena cava syndrome, only ~10 % of patients present this way. Ten to twenty percent of patients present with brain metastases at diagnosis, but by 2 years, 50 % will have developed brain metastases. The median survival of extensive- stage disease with chemotherapy with or without radiation is 7-11 months. Median survival of limited-stage disease is 20-22 months.

Front 13

What percentage of patients with small-cell lung cancer with superior vena cava syndrome presents with a normal chest radiograph? A. 5 % B. 15 % C. 25 % D. 35 %

Back 13

The correct answer is B. Fifteen percent of patients with superior vena cava syndrome from small-cell lung cancer have a normal chest radiograph. Armstrong BA et al. Role of irradiation in the management of superior vena cava syndrome.

Front 14

What was the overall survival benefit seen in both the Pignon and Warde metaanalyses regarding the addition of thoracic radiotherapy to chemotherapy for small-cell lung cancer? A. 5 % B. 7 % C. 10 % D. 12 %

Back 14

The correct answer is A. Both the Pignon and Warde meta-analyses comparing chemotherapy alone with chemotherapy plus thoracic radiotherapy showed a 5.4 % overall survival benefit. The Warde meta-analysis also showed a 25 % improvement in intrathoracic tumor control with the addition of radiotherapy.

Front 15

Regarding the optimal timing of thoracic radiotherapy, reported by Murray et al. in the NCI Canada Study, all of the following are true except: A. Early radiotherapy started with the second cycle of chemotherapy. B. One component of chemotherapy included adriamycin. C. Total radiotherapy dose was 40 Gy. D. Early thoracic radiotherapy improved overall survival, but not local control.

Back 15

The correct answer is C. In the NCI Canada study of the optimal timing of thoracic radiotherapy, 308 patients with limited-stage disease were randomized to early thoracic radiotherapy given with the second cycle of chemotherapy versus late thoracic radiotherapy given with the sixth cycle of chemotherapy. Chemotherapy consisted of cytoxan/adriamycin/vincristine alternating with cisplatin/etoposide for a total of 6 cycles; total radiotherapy dose was 40 Gy/15 fractions. At the end of chemoradiation, those without progression received prophylactic cranial irradiation (25 Gy/10 fractions). Early thoracic radiotherapy was found to improve progression-free survival and overall survival, but not local control (both 50 % at 3 years).

Front 16

According to a meta-analysis by Fried et al. regarding the timing of thoracic radiotherapy in addition to chemotherapy, which of the following constitutes "early" thoracic radiotherapy? A. Beginning within 7 weeks of starting chemotherapy B. Beginning within 8 weeks of starting chemotherapy C. Beginning within 9 weeks of starting chemotherapy D. Beginning within 10 weeks of starting chemotherapy

Back 16

The correct answer is C. In a meta-analysis of 7 trials ( n = 1,524 patients) regarding the timing of thoracic radiotherapy in addition to chemotherapy for limited-stage SCLC, Fried et al. found that initiating radiotherapy within 9 weeks of starting chemotherapy conferred a 2-year overall survival benefit of 5.2 %, similar to the magnitude of adding thoracic radiotherapy to chemotherapy.

Front 17

According to the Intergroup 0096 (Turrisi) trial comparing once daily versus twice daily radiotherapy for small-cell lung cancer, all of the following are true except: A. Grade 3 esophagitis was increased in the twice daily radiotherapy arm. B Overall survival was improved in the twice daily radiotherapy arm. C. The 5- year overall survival in the once daily radiotherapy arm was 10 %. D. Dose per fraction in the once daily radiotherapy arm was 1.8 Gy.

Back 17

The correct answer is C. Intergroup 0096 compared daily radiotherapy 1.8- 45 Gy to BID radiotherapy of 1.5-45 Gy, with concurrent cisplatin/etoposide, beginning on day 1. Twice daily radiotherapy yielded a survival advantage compared to daily radiotherapy, with 5-year OS (26 % vs. 16 %, p = 0.04), though the incidence of grade 3 esophagitis also increased (27 % vs. 11 %, p < 0.001). Starting with week 2, delivery of the afternoon fraction in the BID arm was delivered with off-cord obliques. Cord tolerance in this study was 36 Gy.

Front 18

What was the spinal cord tolerance in the BID fractionation arm of the Intergroup 0096 (Turrisi) trial? A. 36 Gy B. 45 Gy C. 50.4 Gy D. 54 Gy

Back 18

The correct answer is A. Intergroup 0096 compared daily radiotherapy 1.8- 45 Gy, to BID radiotherapy of 1.5-45 Gy, with concurrent cisplatin/etoposide, beginning on day 1. Twice daily radiotherapy yielded a survival advantage compared to daily radiotherapy, with 5-year OS (26 % vs. 16 %, p = 0.04), though the incidence of grade 3 esophagitis also increased (27 % vs. 11 %, p < 0.001). Starting with week 2, delivery of the afternoon fraction in the BID arm was delivered with off-cord obliques. Cord tolerance in this study for the BID arm was 36 Gy.

Front 19

What was the rate of grade three esophagitis in the BID fractionation arm of the Intergroup 0096 (Turrisi) trial? A. 11 % B. 20 % C. 27 % D. 33 %

Back 19

The correct answer is C. Intergroup 0096 compared daily radiotherapy 1.8- 45 Gy, to BID radiotherapy of 1.5-45 Gy, with concurrent cisplatin/etoposide, beginning on day 1. Twice daily radiotherapy yielded a survival advantage compared to daily radiotherapy, with 5-year OS (26 % vs. 16 %, p = 0.04), though the incidence of grade 3 esophagitis also increased (27 % vs. 11 %, p < 0.001). Starting with week two, delivery of the afternoon fraction in the BID arm was delivered with off-cord obliques. Cord tolerance in this study for the BID arm was 36 Gy.

Front 20

Which of the following prophylactic cranial irradiation fractionation schemes has not been typically described for small-cell lung cancer? A. 8 Gy in 1 fraction B. 30 Gy in 10 fractions C. 36 Gy in 18 fractions D. 18 Gy in 10 fractions

Back 20

The correct answer is D. Of the listed prophylactic cranial irradiation (PCI) fractionation schemes, 18 Gy in 10 fractions has not been extensively studied in small-cell lung cancer, though it is used for PCI in acute lymphoblastic leukemia. A multicenter trial in the United Kingdom reported by Gregor et al. described outcomes for patients with limited-stage SCLC +/- PCI. Reported fractionation delivered included 8 Gy in 1 fraction, 30 Gy in 10 fractions, and 36 Gy in 18 fractions. There was a reduction seen in brain relapse at 2 years in those that received PCI, from 59 % to 29 % ( p = 0.0002), though this did not translate into an overall survival benefit.

Front 21

What was the survival benefit seen in those with limited-stage small-cell lung cancer given prophylactic cranial irradiation after a complete response in the Auperin meta-analysis? A. 5 % B. 10 % C. 15 % D. 20 %

Back 21

The correct answer is A. The meta-analysis by Auperin et al. included seven randomized trials and found that PCI after a complete response in limited- stage SCLC conferred a 5.4 % survival benefit, similar to that of adding thoracic radiotherapy to chemotherapy.

Front 22

Regarding the published results from Le Pechoux et al. regarding optimal prophylactic cranial irradiation dose, which of the following is not true? A. Patients had to be in complete remission prior to randomization for PCI. B. Both extensive and limited-stage responders were eligible to randomization. C. Patients were randomized to receive either 25 Gy or 36 Gy. D. There was no significant reduction in the total incidence of brain metastases with higher dose.

Back 22

The correct answer is B. Optimal PCI dose was studied in a randomized trial by Le Pechoux et al. Patients with limited-stage small-cell lung cancer in complete remission were randomized to receive either 25 Gy in 10 fractions or 36 Gy. The 36 Gy could be delivered conventionally in 18 fractions or with an accelerated hyperfractionated approach of BID fractions of 1.5 Gy _~ 12 days of treatment. There was no difference in the 2-year incidence of brain metastases: 29 % standard versus 23 % high dose. The 2-year overall survival was 42 % in the standard- dose arm and 37 % in the high-dose arm, but this is felt to represent increased cancer-related death rather than treatment-related mortality. Twenty five gray remains the standard dose for limited-stage small-cell PCI.

Front 23

Regarding the addition of thoracic radiotherapy in extensive-stage small- cell lung cancer, which of the following observations from Jeremic et al. is not true? A. Patients with a complete response at distant sites were eligible. B. Patients randomized to receive radiotherapy were treated to 45 Gy with BID fractionation. C. Patients that received thoracic radiotherapy had significantly improved survival compared to those that did not receive thoracic radiotherapy. D. Concurrent carboplatin was given with thoracic radiotherapy.

Back 23

The correct answer is B. Jeremic et al. reported results from their prospective randomized trial in which patients with extensive-stage small-cell lung cancer that experienced a complete response at distant sites and complete/partial response of intrathoracic disease after 3 cycles of cisplatin/etoposide were ran- domized to either receive (1) BID thoracic radiotherapy to 54 Gy with concur- rent carboplatin followed by 2 cycles cisplatin/etoposide or (2) 4 cycles of cisplatin/etoposide alone. Those that received thoracic radiotherapy experi- enced significantly improved survival versus those that did not, MS: 17 months versus 11 months, p=0.041.

Front 24

Regarding prophylactic cranial irradiation (PCI) given for those with extensive stage small-cell lung cancer as reported by Slotman et al., which of the following is true? A. There was a 5.4 % survival benefit associated with PCI at 3 years. B. A complete response was not required before PCI was given. C. Brain imaging to confirm the absence of brain metastases was required before PCI. D. Acceptable doses for PCI ranged from 20 Gy to 30 Gy.

Back 24

The correct answer is B. In contrast to the Auperin meta-analysis for PCI with limited-stage small-cell lung cancer, a complete response was not required for those with extensive-stage small-cell lung cancer – ANY response was accept- able. Brain imaging was not required as a standard staging or follow-up proce- dure, unless symptoms indicative of brain metastases were present. Acceptable dose/fractionation schemes were 20 Gy in 5 or 8 fractions, 24 Gy in 12 frac- tions, 25 Gy in 10 fractions, or 30 Gy in 10 or 12 fractions. There was a 5.4 % survival benefit at 3 years seen with PCI in limited-stage small-cell lung cancer. At 1 year, survival after PCI for extensive-stage small-cell lung cancer was 27.1 % versus 13.3 %.

Front 25

Regarding the National Lung Screening Trial, all of the following are true except: A. Participants were randomized to undergo either low-dose CT or chest radiograph screening. B. Participants underwent a total of four screenings at 1-year intervals. C. Any nodule on low-dose CT .4 mm was classified as suspicious for lung cancer. D. Former smokers were required to have quit within 15 years of enrollment.

Back 25

The correct answer is B. The National Lung Screening Trial randomized 53, 454 participants at high risk for the development of lung cancer (history of 30 pack years smoking or former smoker quit within 15 years) to undergo three screenings at yearly intervals by either low-dose CT or chest radiograph. The incidence of lung cancer was 645 cases per 100,000 by low-dose CT, with 247 deaths from lung cancer versus 572 cases per 100,000 in the chest x-ray group, with 309 deaths. The death rate from any cause was reduced by 6.7 % compared to the radiograph group

Front 26

What level in the mediastinum are prevascular lymph nodes? A. 2 B. 3 C. 4 D. 5

Back 26

The correct answer is B. Mediastinal prevascular lymph nodes are level 3.

Front 27

Mediastinal level 5 lymph nodes are best evaluated via which of the following? A. Endoscopic ultrasound with fine-needle aspiration B. Video-assisted thoracoscopy C. Chamberlain procedure D. CT-guided biopsy

Back 27

The correct answer is C. Lymph nodes in mediastinal level 5 (aortopulmonary window) are best evaluated through a Chamberlain procedure, also known as an anterior mediastinotomy. Lymph nodes adjacent to the trachea, levels 2L, 2R, 4R, 4L, and 7, are best evaluated by cervical mediastinoscopy. EUS-FNA can be performed for mediastinal nodes that can be accessed from the esophagus, particularly levels 7, 8, and 9. CT-guided biopsies are used most frequently to evaluate peripheral parenchymal lung nodules.

Front 28

From which lobe is there frequent nodal drainage to the contralateral paratracheal and anterior mediastinal lymph nodes? A. Right upper lobe B. Right middle lobe C. Left upper lobe D. Lingula

Back 28

The correct answer is C. Tumors in the left upper lobe frequently drain to the contralateral paratracheal and anterior mediastinal lymph nodes.

Front 29

What 7th edition AJCC TNM stage is most appropriate for a 3.5-cm adenocarcinoma of the left upper lobe of the lung with a separate 2.9-cm nodule in the left lower lobe without mediastinal or hilar lymph node metastases? A. T2aM1 B. T4N0 C. T4M1 D. T2bM1

Back 29

The correct answer is B. Nodules in different lobes of the ipsilateral lung are now classified as T4 in the AJCC 7th edition. There were classified at M1 in the prior edition. T2 tumors are subclassified by size: T2a (3 cm to .5 cm) or T2b (5 cm to .7 cm)

Front 30

What 7th edition AJCC TNM stage is most appropriate for a 3.5-cm adenocarcinoma of the right upper lobe of the lung with a 2.0-cm left supraclavicular lymph node metastasis? A. T2aN3 B. T2bN3 C. T2aM1 D. T2bM1

Back 30

The correct answer is A. In the AJCC 7th edition, supraclavicular lymph node metastases, whether they are ipsilateral or contralateral, are classified as N3. T2 tumors are subclassified by size: T2a (3 cm to .5 cm) or T2b (5 cm to .7 cm).

Front 31

What 7th edition AJCC TNM stage is most appropriate for a 7-cm squamous cell carcinoma of the right upper lobe of the lung with an ipsilateral pleural effusion and ipsilateral hilar lymph node involvement? A. T4N1M0 B. T4N1M1a C. T3N1M1a D. T3N1M1b

Back 31

The correct answer is C. In the AJCC 7th edition, T3 tumors are classified as those >7 cm; directly invading pleura, chest wall, diaphragm, or phrenic nerve; with associated atelectasis of the entire lobe; invasion of the distal 2 cm of the mainstem bronchus without involvement of the carina; or separate tumor nod- ules in the same lobe. Ipsilateral hilar lymph node involvement is classified as N1. Pleural effusions are classified as M1a in the AJCC 7th edition; they were previously T4. M1b refers to distant metastases.

Front 32

All of the following are true regarding adenocarcinoma of the lung except: A. It can arise out of an old tuberculosis scar. B. It has the fastest doubling time of all subtypes of non-small-cell lung cancer. C. Stage-for-stage outcomes are worse compared to squamous cell lung cancer. D. It most commonly presents in a peripheral location.

Back 32

The correct answer is B. Adenocarcinoma most commonly (75 %) presents in a peripheral location and can arise out of old tuberculosis scars. It has the slowest doubling time of non-small-cell lung cancer subtypes, and stage-for-stage has worse outcomes than squamous cell carcinoma.

Front 33

Which of the following subtypes of lung cancer is least related to smoking? A. Bronchioalveolar carcinoma B. Squamous cell carcinoma C. Small-cell carcinoma D. Large-cell carcinoma

Back 33

The correct answer is A. Of the listed subtypes of lung cancer, bronchioalveolar carcinoma is least related to smoking. Ebbert JO et al. Clinical features of bronchioalveolar carcinoma with new histologic and staging definitions.

Front 34

Which of the following was not found to be one of the three most important prognostic factors affecting survival in inoperable bronchogenic carcinoma of the lung, as reported in the Veterans Administration Lung Group Protocols? A. Karnofsky performance status B. Extent of disease C. Weight loss in the previous 6 months D. Response to treatment

Back 34

The correct answer is D. More than 5,000 patients with inoperable bronchogenic carcinoma of the lung were entered in Veterans Administration Lung Group Protocols 9-15. Through these, the three most important prognostic factors affecting survival were found to be Karnofsky performance status, extent of disease, and weight loss in the previous 6 months.

Front 35

Comparing lobectomy versus limited resection, which of the following statements regarding the Lung Cancer Study Group trial is incorrect? A. Participants with T1N0M0 lung cancer were randomized to lobectomy versus limited resection. B. There was no difference in local control between the two arms. C. Cancer-related mortality was worse in the limited resection arm. D. No participants in the limited resection group required postoperative ventilation for 24 h.

Back 35

The correct answer is B. Participants in the Lung Cancer Study Group trial were randomized to undergo lobectomy versus limited resection for T1N0M0 lung cancer. There was significantly improved local control in those that underwent lobectomy; cancer mortality was increased in those that underwent limited resection, 62 % versus 55 %. Those that underwent wedge resection had a three- fold increase in local recurrence; those that underwent segmental resection had a 2.4-fold increase in local recurrence. Of those that underwent limited resection, none required postoperative ventilation >24 h. While the intent of the study was to show the equivalence of limited resection and lobectomy, given the increased local recurrence and cancer mortality associated with limited resection, the conclusion of the study was that lobectomy should remain the standard surgical treatment.

Front 36

What is the best evidence-based treatment approach for an operable small T1a peripheral NSCLC? A. Lobectomy B. Wedge resection C. Stereotactic body radiation therapy D. Definitive chemoradiation

Back 36

The correct answer is A. There is data showing that SBRT is an excellent therapy for medically inoperable early-stage lung tumors. While RTOG 0618, a phase II trial of SBRT in the treatment of medically operable stage I/II NSCLC, has completed accrual, for now, surgical resection remains the gold standard for operable NSCLC. Regarding the optimal surgery for resection of early-stage NSCLC, CALGB 140503 is an open phase III study looking at lobectomy versus sublobar resection for peripheral NSCLC tumors <2 cm. RTOG 1021/ACOSOG Z4099 is currently enrolling on a phase III trial comparing sublobar resection +/. brachytherapy versus SBRT in high-risk surgical patients with stage I NSCLC.

Front 37

What is the 5-year overall survival of a cT1N0 lung cancer per the Mountain data? A. 90 % B. 80 % C. 70 % D. 60 %

Back 37

The correct answer is D. The Mountain data include clinical, surgical, pathologic, and follow-up data from 5319 combined consecutive patients with lung cancer (4351 treated at M. D. Anderson Cancer Center and 968 from the Reference Classification for Anatomic and Pathologic Classification of Lung Cancer database). The 5-year overall survival of a cT1N0 lung cancer is 61 %.

Front 38

What is the 5-year overall survival of a pT1N0 lung cancer per the Mountain data? A. 90 % B. 80 % C. 70 % D. 60 %

Back 38

The correct answer is C. The Mountain data include clinical, surgical, pathologic, and follow-up data from 5319 combined consecutive patients with lung cancer (4351 treated at M. D. Anderson Cancer Center and 968 from the Reference Classification for Anatomic and Pathologic Classification of Lung Cancer database). The 5-year overall survival of a pT1N0 lung cancer is 67 %.

Front 39

Regarding the published results of RTOG 0236 (JAMA 2010), a phase II study looking at stereotactic body radiation therapy in medically inoperable earlystage lung cancer, which of the following is true? A. T2 tumors were excluded from enrollment. B. The prescription dose was 18 Gy x 3 fractions. C. Three-year overall survival was 55 %. D. Three-year primary tumor control rate was 85 %.

Back 39

The correct answer is C. RTOG 0236 was a phase II study in which early- stage, medically inoperable NSCLC was treated with SBRT (prescription dose 20 Gy x 3 fractions without heterogeneity corrections). Both T1 and T2 tumors were included. Three-year primary tumor control rate was excellent (97.6 %), though there was a 22 % 3-year distant failure rate. Three-year overall survival was 55.8 %.

Front 40

Which of the following was found to be the treated BED equal to or over which there was a statistically signifi cant improvement in both local control and overall survival, as described by Onishi et al.? A. .90 Gy B. .95 Gy C. .100 Gy D. .105 Gy

Back 40

The correct answer is C. Describing their experience in which 257 patients with operable stage I NSCLC were treated with hypofractionated radiation (doses ranging 18.75 Gy at the isocenter in 1.22 fractions), Onishi et al. reported that those treated with a dose of BED ≥ 100 Gy has statistically decreased 5-year local recurrence (8.4 % vs. 42.9 %, p < 0.001) and statistically increased 5-year overall survival (70.8 % vs. 30.2 %, p < 0.05). With these higher reported overall survivals, it is important to remember that these are operable patients.

Front 41

Regarding postoperative radiotherapy for lung cancer, all of the following are conclusions from the postoperative radiotherapy meta-analysis except: A. There was an absolute overall survival detriment of 7 % associated with postoperative radiotherapy in N0/N1 patients. B. Postoperative radiotherapy was associated with improved survival in patients with N2 disease. C. Both published and unpublished trials were included to avoid publication bias. D. Postoperative radiotherapy doses ranged from 30 to 60 Gy.

Back 41

The correct answer is B. The original PORT Meta-analysis published in 1998 included both published and unpublished trials ( n = 9). Postoperative radiotherapy doses ranged from 30 to 60 Gy, and postoperative radiotherapy was associated with a 7 % absolute detriment in overall survival. This effect was seen mostly in N0/N1 patients. The role in N2 disease is less clear, while there is no benefit, there is no detriment seen.

Front 42

All are true regarding the Lung Cancer Study Group 773 Trial of postoperative radiotherapy for non-small-cell lung cancer as reported by Weisenberger et al. except: A. Adenocarcinoma was not included. B. Postoperative radiation dose was 50 Gy. C. Local control was improved only in patients with N2 disease. D. There was no overall survival benefit for the addition of radiation.

Back 42

The correct answer is C. In the LCSG 773 trial, 210 patients with either T1-2/ N1 or T3 or T, any N2 squamous cell carcinoma of the lung were randomized after surgery to observation or postoperative radiotherapy (50 Gy). The addition of postoperative radiotherapy improved local control for all patients, even those with only N1 disease, but there was no overall survival benefit. In N2 patients, there was a trend towards improved survival.

Front 43

All are true regarding the Medical Research Council study of postoperative radiotherapy for non-small-cell lung cancer as reported by Stephens et al. except: A. Negative margins were required. B. Postoperative radiation dose was 40 Gy. C. Local recurrence was improved only in patients with N2 disease. D. Median survival was not improved with the addition of radiation in any subgroup.

Back 43

The correct answer is D. The Medical Research Council (MRC) Trial of postoperative radiotherapy randomized 308 patients with R0 resected (negative margins) pT1-2/N1-2 lung cancer to either observation or postoperative radiotherapy
(40 Gy/15 fractions). The addition of postoperative radiotherapy did not show any benefit in patients with N1 disease. However, subset analysis of those with N2 disease showed improved local control and a 1-month gain in median survival (17.6 months vs. 16.2 months). Stephens RJ et al. The role of postoperative radiotherapy in non-small-cell lung cancer: a multicentre randomised trial in patients with pathologically stage T1-2, N1-2, M0 disease.

Front 44

Regarding adjuvant chemotherapy in lung cancer, which of the following statements about the International Adjuvant Lung Cancer Trial (IALT) is not true? A. Participants were not allowed to receive adjuvant radiotherapy. B. Participants were randomized to observation versus an adjuvant cisplatin doublet. C. Adjuvant chemotherapy was associated with a 4 % absolute survival benefit. D. The survival benefit seen with adjuvant chemotherapy was present for all stage groups.

Back 44

The correct answer is A. The International Adjuvant Lung Cancer Trial (IALT) randomized 1867 patients after surgery to observation versus chemotherapy with a cisplatin doublet. The second agent (etoposide, vindesine, vinblastine, vinorelbine) was given as per institutional preference. Radiation therapy was permitted after the completion of chemotherapy. Adjuvant chemotherapy was associated with a 4 % absolute benefit in 5-year OS (44 % vs. 40 %, p < 0.03), and this benefit was present for all stage groups.

Front 45

All of the following are true statements about the CALGB 9633 trial which randomized resected T2N0M0 NSCLC to observation versus adjuvant carboplatin/paclitaxel except: A. Adjuvant chemotherapy consisted of 4 cycles of carboplatin/paclitaxel. B. Neutropenia was the predominant toxicity seen with chemotherapy. C. There was a statistically significant survival benefit of chemotherapy only in those with tumors .4 cm. D. Only half of patients randomized to receive chemotherapy received all of the planned cycles.

Back 45

The correct answer is D. CALGB 9633 randomized postoperative T2N0M0 tumors to observation versus 4 cycles of adjuvant carboplatin/paclitaxel. Eightysix percent of patients were able to receive all 4 cycles, and of these patients, 66 % were able to receive the full doses. Neutropenia was the predominant grade 3/4 toxicity. Looking at all the T2 tumors, there was no survival benefit to adjuvant chemotherapy. On subset analysis, those with tumors .4 cm who received chemotherapy did demonstrate a significant improvement in overall survival.

Front 46

In the randomized trial comparing preoperative chemotherapy plus surgery versus surgery alone as reported by Rosell et. al., all of the following are true except: A. All patients received mediastinal radiotherapy after surgery. B. Preoperative chemotherapy consisted of 3 cycles of cisplatin/etoposide. C. Median survival was improved in those receiving preoperative chemotherapy. D. Local recurrence was greater in those that did not receive preoperative chemotherapy.

Back 46

The correct answer is B. The preoperative trial reported by Rosell et al. randomized 60 patients with stage IIIA NSCLC to either undergo preoperative chemotherapy with 3 cycles of mitomycin, ifosfamide, and cisplatin followed by surgery or surgery alone. All patients received postoperative mediastinal radiation to 50 Gy. Median survival was improved in those that received combined therapy, 26 versus 8 months ( p < 0.001). Median disease-free survival was also improved: 20 versus 5 months ( p < 0.001), as was the rate of local recurrence, 56 % versus 74 %.

Front 47

In the CALGB 8433 trial (Dillman et al.) comparing induction chemotherapy plus radiotherapy versus radiotherapy alone, all of the following are true except: A. Total radiotherapy dose in both arms was 60 Gy. B. Only patients with stage III NSCLC were eligible. C. Median survival was improved with the addition of induction chemotherapy. D. Induction chemotherapy consisted of cisplatin and etoposide.

Back 47

The correct answer is D. The CALBG 8433 trial as reported by Dillman et al. randomized patients with stage III NSCLC - either by clinical or surgical staging - to receive either induction cisplatin on d 1 and 29 or vinblastine on d 1,8, 15, 22, and 29 + radiotherapy to 60 Gy versus definitive radiotherapy alone to 60 Gy. As reported in the JNCI with more than 7 years of follow-up, the addition of induction chemotherapy improved median survival to 13.7 m compared to 9.6 m ( p = 0.012).

Front 48

The Intergroup 0139 trial randomized patients with NSCLC to undergo chemoradiation alone versus chemoradiation + surgery. All of the following are true statements about 0139 except: A. N2 nodal status was required for eligibility. B. Chemotherapy consisted of cisplatin and etoposide for a total of 4 cycles. C. Total radiotherapy dose in the chemoradiation alone arm was 63 Gy. D. Total radiotherapy dose in the preoperative chemoradiation arm was 45 Gy.

Back 48

The correct answer is C. Intergroup 0139 randomized patients with stage IIIA NSCLC with ipsilateral N2 nodes to undergo either definitive chemoradiation (cisplatin/etoposide x 2 cycles concurrent to 61 Gy) followed by two additional cycles of cisplatin/etoposide versus preoperative chemoradiation with 2 cycles of concurrent cisplatin/etoposide to 45 Gy, then resection if there was no progression, followed by two additional cycles of cisplatin/etoposide. There was no difference in survival between the two arms, though progression-free survival and local control were both improved with the addition of surgery. No differences were noted in the first site of progression. On exploratory analysis, those that underwent lobectomy rather than pneumonectomy were found to have significantly improved survival (MS, 33.6 months vs. 21.7 months). Neutropenia was the most common grade 3 or 4 toxicity; esophagitis was the second most common grade 3 or 4 toxicity.

Front 49

All of the following are outcomes from the Intergroup 0139 trial which randomized patients with NSCLC to undergo chemoradiation alone versus chemoradiation + surgery except: A. Esophagitis was the most common grade 3 or 4 toxicity. B. Overall survival was not improved with the addition of surgical resection. C. Progression-free survival was improved with the addition of surgery. D. Overall survival was improved in those who underwent lobectomy, but not pneumonectomy.

Back 49

The correct answer is A. Intergroup 0139 randomized patients with stage IIIA NSCLC with ipsilateral N2 nodes to undergo either definitive chemoradiation (cisplatin/etoposide x 2 cycles concurrent to 61 Gy) followed by two additional cycles of cisplatin/etoposide versus preoperative chemoradiation with 2 cycles of concurrent cisplatin/etoposide to 45 Gy, then resection if there was no progression, followed by two additional cycles of cisplatin/etoposide. There was no difference in survival between the two arms, though progression-free survival and local control were both improved with the addition of surgery. No differences were noted in the first site of progression. On exploratory analysis, those that underwent lobectomy rather than pneumonectomy were found to have significantly improved survival (MS, 33.6 months vs. 21.7 months). Neutropenia was the most common grade 3 or 4 toxicity; esophagitis was the second most common grade 3 or 4 toxicity.

Front 50

What trial initially established 60 Gy as the standard dose for unresectable, locally advanced NSCLC? A. RTOG 73-01 B. RTOG 83-11 C. RTOG 88-08 D. RTOG 94-10

Back 50

The correct answer is A. RTOG 73-01 established 60 Gy as the standard dose for locally advanced NSCLC. In this randomized study, 365 patients with unresectable NSCLC were randomized to one of four arms: 40 Gy split course, 40 Gy continuous, 50 Gy continuous, and 60 Gy continuous. Survival was worst in the split-course arm, 10 % at 2 years. There was a dose response noted in terms of increased tumor regression and decreased intrathoracic recurrence, with increasing dose. The most frequent complications were pneumonitis, pulmonary fibrosis, and dysphagia from transient esophagitis. RTOG 94-10 reported by Curran et al. established the survival benefit of concurrent chemoradiation with standard fractionation over sequential chemotherapy then radiation.

Front 51

Which of the following is least likely to increase the risk of pneumonitis? A. Increased total radiation dose B. Increased volume of lung irradiated C. Poor pulmonary function from underlying COPD D. Treatment of upper lobe tumor

Back 51

The correct answer is D. Treatment of an upper lobe tumor is least likely to increase the risk of pneumonitis, likely due to the decreased volume of lung treated. All the others increase the risk of pneumonitis. Lind P et al. Receiver operating characteristic curves to assess predictors of radiation-induced symptomatic lung injury.

Front 52

Regarding the use of amifostine as a radioprotectant during irradiation for NSCLC, all of the following are true except: A. Amifostine is a thioester that scavenges free radicals. B. Hypotension is a frequent side effect. C. It has been shown to significantly improve objective measures of esophagitis. D. Its trade name is EthyolR.

Back 52

The correct answer is C. Amifostine, trade name EthyolR, is a thioester that scavenges free radicals. It is usually delivered IV or SC shortly prior to radiotherapy. Hypotension is the most common side effect observed. While it has been shown to decrease xerostomia when treating H&N tumors, there was no statistically significant improvement in measured grade 3 esophagitis in a phase III study with concurrent irradiation, carboplatin, and paclitaxel.

Front 53

What was the rate of esophagitis in the amifostine arm of RTOG 98-01, a phase III trial of non-small-cell lung cancer treated with chemoradiation with or without amifostine? A. 15 % B. 20 % C. 25 % D. 30 %

Back 53

The correct answer is D. In RTOG 98-01, 243 patients with stage II. IIIA/B non-small-cell lung cancer first received induction carboplatin/paclitaxel on days 1 and 22, followed by concurrent chemoradiation to 69.6 Gy/1.2 Gy BID with weekly carboplatin and paclitaxel with or without amifostine (500 mg/m 2 , four times per week). The majority of patients randomized to amifostine (72 %) received amifostine either per protocol or with only a minor deviation. There was no difference in the rate of grade 3 esophagitis (30 % vs. 34 %, p = 0.9) with the addition of amifostine.

Front 54

All of the following statements regarding the NSCLC dose escalation RTOG 0617 trial are true except: A. There was no survival benefi t for treatment with 74 Gy versus 60 Gy. B. Toxicity rates were no different between the arms. C. Standard concurrent chemotherapy in all arms was carboplatin/paclitaxel. D. All arms of the trial were closed after the high-dose arms crossed the futility boundary.

Back 54

The correct answer is D. RTOG 0617 is a 4-arm study with two purposes: (1) ascertain benefi t of dose escalation and (2) ascertain benefi t of addition of anti-EGFR therapy with cetuximab to standard chemotherapy. Patients with stage IIIA or B NSCLC were stratifi ed according to RT technique (3D-CRT vs. IMRT), Zubrod performance status (0 vs. 1), use of PET staging (yes vs. no), and histology (squamous vs. non-squamous) to one of four arms: (1) chemoRT to 60 Gy, (2) chemoRT to 74 Gy, (3) chemoRT + cetuximab to 60 Gy, and (4) chemoRT + cetuximab to 74 Gy. Standard chemotherapy in all arms consisted of carboplatin (AUC = 2/week) and paclitaxel (45 mg/m 2 / week). Cetuximab was given as a loading dose of 400 mg/m 2 on day 1, then weekly at 250 mg/m 2 each subsequent week. All arms were to subsequently receive 2 cycles of consolidation chemotherapy with or without cetuximab depending on their randomization. Critical structure constraints included keeping the total lung V20 . 37 %...

Front 55

All of the following regarding the NSCLC dose escalation RTOG 0617 trial are true except: A. All patients were planned to receive consolidation chemotherapy. B. IMRT was not allowed. C. One of the stratification features was use of PET staging. D. The total lung V20 was to be kept .37 %.

Back 55

The correct answer is B. RTOG 0617 is a 4-arm study with two purposes: (1) ascertain benefi t of dose escalation and (2) ascertain benefi t of addition of anti- EGFR therapy with cetuximab to standard chemotherapy. Patients with stage IIIA or B NSCLC were stratifi ed according to RT technique (3D-CRT vs. IMRT), Zubrod performance status (0 vs. 1), use of PET staging (yes vs. no), and histology (squamous vs. non-squamous) to one of four arms: (1) chemoRT to 60 Gy, (2) chemoRT to 74 Gy, (3) chemoRT + cetuximab to 60 Gy, and (4) chemoRT + cetuximab to 74 Gy. Chemotherapy in all arms consisted of carboplatin
(AUC = 2/week) and paclitaxel (45 mg/m 2 /week). Cetuximab was given as a loading dose of 400 mg/m 2 on day 1, then weekly at 250 mg/m 2 each subsequent week. All arms were to subsequently receive 2 cycles of consolidation chemotherapy with or without cetuximab depending on their randomization. Critical structure constraints included keeping the total lung V20 . 37 %...

Front 56

Which of the following was NOT an arm of the LAMP trial as reported by Belani et al.? A. Induction chemotherapy, followed by radiotherapy alone to 63 Gy B. Induction chemotherapy followed by concurrent chemoradiation C. Concurrent chemoradiation alone D. Concurrent chemoradiation followed by consolidative chemotherapy

Back 56

The correct answer is C. The LAMP trial randomized 257 patients to one of three arms: (1) induction carbo/taxol x 2 cycles, with radiation alone to postchemotherapy volume (63 Gy) starting on day 42; (2) induction carbo/taxol x 2 cycles, followed by concurrent chemoradiation to 63 Gy, concurrent chemo = weekly taxol with q3week carbo x 2 cycles; and (3) concurrent chemoradiation followed by 2 cycles of consolidative chemotherapy, concurrent chemo = weekly taxol with q3week carbo x 2 cycles. Arm two was closed after an early interim analysis. Those patients in the consolidative chemotherapy arm had the highest percentage of completion of the scheduled radiotherapy dose (81 % vs. 76 % and 70 % in the other two arms). Neutropenia was the most common grade 3 or 4 toxicity. There was increased esophagitis in the concurrent chemoradiation arms. With a median follow-up of 39.6 months, there was no difference in MS between the arms, 13 versus 12.7 versus 16.3 months...

Front 57

Which of the following is not an observation from the LAMP trial as reported by Belani et al.? A. Neutropenia was the most common grade 3 or 4 toxicity. B. Esophagitis was worst in the concurrent chemoradiation arms. C. Median survival seemed to be improved with the addition of consolidative chemotherapy. D. Those patients in the consolidative chemotherapy arm had the lowest percentage of completion of the scheduled radiotherapy dose.

Back 57

The correct answer is D. The LAMP trial randomized 257 patients to one of three arms: (1) induction carbo/taxol x 2 cycles, with radiation alone to postchemotherapy volume (63 Gy) starting on day 42; (2) induction carbo/taxol x 2 cycles, followed by concurrent chemoradiation to 63 Gy, concurrent chemo = weekly taxol with q3week carbo x 2 cycles; and (3) concurrent chemoradiation followed by 2 cycles of consolidative chemotherapy, concurrent chemo = weekly taxol with q3week carbo x 2 cycles. Arm two was closed after an early interim analysis. Those patients in the consolidative chemotherapy arm had the highest percentage of completion of the scheduled radiotherapy dose (81 % vs. 76 % and 70 % in the other two arms). Neutropenia was the most common grade 3 or 4 toxicity. There was increased esophagitis in the concurrent chemoradiation arms. With a median follow-up of 39.6 months, there was no difference in MS between the arms, 13 versus 12.7 versus 16.3 months...

Front 58

What was the elective nodal failure in those patients with NSCLC treated with involved nodal radiotherapy only as reported by Rosenzweig et al.? A. 4 % B. 6 % C. 8 % D. 10 %

Back 58

The correct answer is B. Rosenzweig et al. reported their experience of treating NSCLC with involved nodal rather than elective nodal irradiation in an effort to decrease toxicity while treating the GTV to a higher dose. Involved nodes were defi ned as lymph nodes pathologically proven to be involved and radiographically .15 mm in the short axis on CT. With a median follow-up of 21 months, they reported 11 of 171 patients (6.4 %) failing in the elective nodal region, with a median time of 4 months to failure. Two-year actuarial rates of elective nodal and primary control were 91 % and 38 %, respectively.

Front 59

All are true regarding the Hoosier Oncology Group consolidation docetaxel trial for inoperable stage III non-small-cell lung cancer as reported by Hanna et al. except: A. Total radiotherapy dose delivered was 59.4 Gy. B. Median survival was not improved with the addition of docetaxel. C. Concurrent chemotherapy consisted of carboplatin/paclitaxel. D. There was increased febrile neutropenia in the docetaxel group.

Back 59

The correct answer is C. The Hoosier Oncology Group Phase III study of concurrent chemoradiation with cisplatin/etoposide to 59.4 Gy with or without consolidation docetaxel x 3 cycles in eligible stage IIIA/IIIB NSCLC patients showed no survival benefit compared to observation after definitive chemoradiation. Of those randomized to consolidation docetaxel, 80.8 % completed all three planned cycles. There was increased toxicity in the docetaxel arm, with 10.9 % experiencing febrile neutropenia and 9.6 % experiencing grade 3.5 pneumonitis, compared to 1.4 % in the observation arm. More patients required hospitalization in the docetaxel arm (28.8 %) compared to the observation arm (8.1 %). Median survival was not improved with docetaxel 21.2 months versus 23.2 months in the observation arm ( p = 0.883).

Front 60

Which of the following statements correctly describes the methods of RTOG 94-10? A. Concurrent chemotherapy in the hyperfractionated arm consisted of cisplatin/ vinblastine. B. Concurrent chemotherapy in the conventionally fractionated arms was cisplatin/etoposide. C. Total radiotherapy dose in conventionally fractionated arms was 60 Gy. D. Total radiotherapy dose in the hyperfractionated arm was 69.2 Gy.

Back 60

The correct answer is D. RTOG 94-10 was the phase III trial that established concurrent chemoradiation as the standard of care for advanced non- small-cell lung cancer. In this study, 610 patients with medically or surgically inoperable stage II. IIIB NSCLC were randomized to one of three arms: (1) induction cisplatin 100 mg/m 2 on days 1 and 29/vinblastine 5 mg/m 2 weekly then 63 Gy starting Day 50 (Dillman 8433 arm); (2) cisplatin 100 mg/m 2 on days 1 and 29/ vinblastine 5 mg/m 2 weekly with radiation to 63 Gy starting on day 1 (concurrent chemoRT arm); and (3) cisplatin 50 mg/m 2 on days 1, 8, 29, and 36/ etoposide 50 mg BID x 10 days on RT days 1-5, 8-12, with radiation to 69.6 Gy in 1.2 Gy BID fractions starting on day 1 (concurrent hyperfractionated arm). With a median follow- up of 11 years, Curran et al. reported improved median survival in the concurrent chemoRT arms. Median survivals were 14.6, 17.0, and 15.6 months in the respective arms. ...

Front 61

Which of the following is not true regarding the RTOG 94-10 trial for inoperable, advanced non-small-cell lung cancer? A. Acute esophagitis was worst in the hyperfractionated arm. B. Late esophagitis was worst in the hyperfractionated arm. C. Median survival was 17 months in the concurrent chemotherapy, conventional RT arm. D. Stage II NSCLC was eligible for enrollment.

Back 61

The correct answer is B. RTOG 94-10 was the phase III trial that established concurrent chemoradiation as the standard of care for advanced non- small-cell lung cancer. In this study, 610 patients with medically or surgically inoperable stage II. IIIB NSCLC were randomized to one of three arms: (1) induction cisplatin 100 mg/m 2 on days 1 and 29/vinblastine 5 mg/m 2 weekly then 63 Gy starting Day 50 (Dillman 8433 arm); (2) cisplatin 100 mg/m 2 on days 1 and 29/ vinblastine 5 mg/m 2 weekly with radiation to 63 Gy starting on day 1 (concurrent chemoRT arm); and (3) cisplatin 50 mg/m 2 on days 1, 8, 29, and 36/etoposide 50 mg BID _~ 10 days on RT days 1.5, 8.12, with radiation to 69.6 Gy in 1.2 Gy BID fractions starting on day 1 (concurrent hyperfractionated arm). With a median follow- up of 11 years, Curran et al. reported improved median survival in the concurrent chemoRT arms. Median survivals were 14.6, 17.0, and 15.6 months in the respective arms...

Front 62

Which of the following was NOT an arm of RTOG 88-08 as reported by Sause et al.? A. 60Gy/30 fractions/6 weeks B. 60Gy/30 fractions/6 weeks with induction cisplatin/etoposide C. 60Gy/30 fractions/6 weeks with induction cisplatin/vinblastine D. 69.2 Gy in twice daily 1.2 Gy fractions

Back 62

The correct answer is B. RTOG 88-08 enrolled 452 patients and randomized them to one of three regimens for locally advanced, surgically unresectable stage II. IIIB NSCLC: (1) standard radiotherapy 60 Gy/30 fx, (2) induction cisplatin/ vinblastine followed by standard radiotherapy (60 Gy/30 fx) starting on day 50, and (3) twice daily radiotherapy (69.2 Gy/BID 1.2 Gy fractions). More than 95 % of patients were stage IIIA or IIIB, and over two thirds had a KPS ≥80. Median survival was highest in the concurrent chemoradiation arm 13.8 months and statistically improved to the other two arms, 11.4 months RT alone and 12.3 months hyperFX ( p = 0.03).

Front 63

All of the following are treatment arms from the Schaake-Koning trial of unresectable non-small-cell lung cancer except: A. Split-course RT alone: 30 Gy then 25 Gy B. Split-course RT with weekly cisplatin C. Split-course RT with daily cisplatin D. Split-course RT with cisplatin on days 1, 22, and 43

Back 63

The correct answer is D. Schaake-Koning et al. randomized 331 patients with unresectable non-small-cell lung cancer to one of three treatment arms: (1) splitcourse RT alone, 30 Gy, then 25 Gy; (2) split-course RT with weekly cisplatin; and (3) split-course RT with daily cisplatin. The addition of chemotherapy improved both local control and overall survival, but significantly increased acute toxicity. There was no benefit to daily cisplatin compared to weekly cisplatin. Schaake-Koning C et al. Effects of concomitant cisplatin and radiotherapy on inoperable non-small cell lung cancer.

Front 64

All are true regarding the United Kingdom CHART regimen for lung cancer as reported by Saunders et al. except: A. CHART did not show a survival benefit compared to conventional radiotherapy. B. The CHART regimen consisted of 54 Gy delivered in TID fractions. C. Acute toxicity was increased in the CHART arm. D. There were no differences in late toxicities between the two arms.

Back 64

The correct answer is A. Continuous hyperfractionated accelerated radiation treatment was studied in the United Kingdom by the Medical Research Council. In this trial, an aggressive TID hyperfractionation regimen to 54 Gy in 12 days was compared to standard 60 Gy/30 fractions. The CHART regimen was found to confer a survival advantage compared to conventional fractionation with 1-year survival improved from 55 % to 63 % and 2-year survival improving from 20 % to 29 %. While there was increased acute toxicity, there was no increase in late toxicity.

Front 65

All of the following are acceptable components of treatment for radiationinduced pneumonitis except: A. Prednisone prescribed at 1 mg/kg/day over a slow taper B. Prednisone 60 mg/day over a slow taper C. Trimethoprim-sulfamethoxazole D. Metronidazole

Back 65

The correct answer is D. Radiation pneumonitis is treated with a slow taper of prednisone, prescribed at either 1 mg/kg/day or 60 mg/day. Along with prednisone, trimethoprim-sulfamethoxazole should be given for PCP prophylaxis

Front 66

The symptom of sudden electric shocks extending down the spine with head flexion infrequently associated with treatment of non-small-cell lung cancer is known as: A. Nelson's syndrome B. Lhermitte's syndrome C. Garcin syndrome D. Lemierre's syndrome

Back 66

The correct answer is B. The symptom of sudden electric shocks extending down the spine with head flexion, infrequently associated with treatment of non- small-cell lung cancer, is known as Lhermitte's syndrome. Nelson's syndrome is enlargement of a pituitary adenoma in a patient with Cushing's disease after removal of the adrenals . results from loss of feedback inhibition of cortisol. Lemierret's syndrome is when an oropharyngeal infection is complicated by internal jugular vein thrombosis and metastatic lung abscesses. Ring enhancement is seen in the internal jugular vein on CT. Garcin syndrome is extensive unilateral cranial palsies associated with malignancy in the nasopharynx or base of skull.

Front 67

Regarding the RTOG 0214 trial evaluation prophylactic cranial irradiation (PCI) for treated advanced-stage non-small-cell lung cancer, which of the following is true? A. PCI total dose was 25 Gy in 10 fractions. B. There was a small disease-free survival benefit with the addition of PCI. C. There was no overall survival benefit with the addition of PCI. D. The 1-year rate of brain metastases was not different between the arms.

Back 67

The correct answer is C. RTOG 0214 randomized 356 patients (target accrual 1058) with stage III NSCLC without disease progression after surgery and/or radiation with or without chemotherapy to either receive prophylactic cranial irradiation (30 Gy in 15 fractions) versus observation. Patients were stratifi ed according to stage (IIIA vs. IIIB), histology (squamous vs. non-squamous), and therapy (surgery vs. none). The study was closed early due to poor accrual. While PCI in patients with treated NSCLC did improve the rate of brain metastasis, it did not improve overall survival nor disease-free survival. One-year OS between the two arms was not statistically different, 75.6 % PCI versus 76.9 % obs ( p = 0.86), nor was disease-free survival. The 1-year rates of brain metastases were significantly different, 7.7 % PCI versus 18 % obs ( p = 0.004).

Front 68

Regarding the SWOG 0023 trial in which consolidation therapy after definitive chemoRT consisted of docetaxel x 3 cycles with or without gefitinib, all of the following are true except: A. Total radiotherapy dose delivered was 61 Gy. B. Cisplatin/etoposide was delivered concurrently. C. Median survival was improved with the addition of gefitinib. D. Stage IIIA and stage IIIB patients were eligible for enrollment.

Back 68

The correct answer is C. The SWOG 0023 trial randomized patients with stage IIIA/B NSCLC after definitive chemoRT and 3 cycles of adjuvant docetaxel to observation versus gefitinib. Concurrent chemotherapy consisted of 2 cycles of cisplatin/etoposide. Total radiotherapy dose delivered was 61 Gy. The addition of gefitinib did not improve progression-free nor median survival. MS was 23 months in the gefitinib group versus 35 months in the observation group.

Front 69

What ipsilateral lung dosimetric constraint will reduce the risk of pneumonitis after chemoradiation for non-small-cell lung cancer to <10 %, as reported by Ramella et al.? A. V20 ipsilateral <52 % B. V20 ipsilateral <42 % C. V30 ipsilateral <30 % D. V30 ipsilateral <35 %

Back 69

The correct answer is A. Ramella et al. published their experience of treating 97 patients with NSCLC treated with 3D-CRT and chemotherapy, incorporating ipsilateral lung dosimetric planning constraints in an effort to predict and minimize radiation pneumonitis. After 3D-CRT treatment planning, patients were only treated if total lung V20 .31 %, V30 .18 %, and mean lung dose .20 Gy. After treatment, total lung and ipsilateral lung dose-volume histogram parameters and total dose delivered were correlated with pneumonitis incidence in an effort to develop additional dosimetric constraints to minimize pneumonitis. They found that the most statistically signifi cant factors predicting pneumonitis were V20ipsilateral (V20 ipsi), V30 ipsilateral (V30ipsi), and planning target volume. Those patients exceeding these ipsilateral constraints were classified as the high-risk group, whereas those meeting ipsilateral criteria were classifi ed as low risk. Risk of pneumonitis for each of the constr

Front 70

Which of the following is not a histologic subtype of malignant mesothelioma? A. Epithelioid B. Large cell C. Sarcomatoid D. Biphasic

Back 70

The correct answer is B. Of the listed histologic subtypes, large cell is a subtype of adenocarcinoma, not malignant mesothelioma.

Front 71

Which histologic subtype of malignant mesothelioma has the best prognosis? A. Epithelioid B. Large cell C. Sarcomatoid D. Biphasic

Back 71

The correct answer is A. Of the listed histologic subtypes of malignant pleural mesothelioma, epithelioid type has the best prognosis.

Front 72

Which biomarker as reported by Pass et al. can help identify early-stage pleural mesothelioma in patients with prior asbestos exposure? A. Chromogranin A B. Nuclear matrix protein 22 C. Osteopontin D. Calcitonin

Back 72

The correct answer is C. Pass et al. described their results from a cohort study comparing 69 patients with asbestos-related nonmalignant pulmonary disease, 45 patients without asbestos exposure, and 76 patients with surgically staged pleural mesothelioma. In this study, they found that osteopontin, a suggested biomarker for pleural mesothelioma, could be identifi ed by enzyme- linked immunoabsorbent assay (ELISA). As such, serum osteopontin levels in persons with exposure to asbestos could be used to identify early-stage (stage I) pleural mesothelioma, as serum osteopontin levels were signifi cantly higher in those with pleural mesothelioma than in the group without exposure to asbestos. Calcitonin is a biomarker for medullary thyroid cancer. Chromogranin A is a biomarker of neuroendocrine tumors. Nuclear matrix protein 22 is a biomarker used to monitor response to treatment in bladder cancer.

Front 73

Which of the following chemotherapy doublets is not approved or recommended by the Food and Drug Administration nor the National Comprehensive Cancer Network? A. Cisplatin/pemetrexed B. Carboplatin/pemetrexed C. Cisplatin/gemcitabine D. Cisplatin/etoposide

Back 73

The correct answer is D. Of the listed chemotherapy doublets, only cisplatin/ pemetrexed is approved by the FDA and was shown in a phase III trial of unresectable malignant pleural mesothelioma to improve survival compared to cisplatin alone (12.1 months vs. 9.3 months, p = 0.02). Cisplatin/gemcitabine is an option for chemotherapy as recommended by the NCCN after it was shown in phase II studies to improve median survival. Carboplatin/pemetrexed is also an acceptable NCCN recommended therapy as it was found in two phase II studies to improve median survival. Cisplatin/etoposide has a role in treating nonsmall- cell lung cancer, not malignant pleural mesothelioma.

Front 74

Regarding the role of radiotherapy for malignant pleural mesothelioma, all of the following are true except: A. It can be used to prevent instrument-tract recurrence after pleural intervention. B. It can be used to palliate chest or bone pain. C. Definitive chemoradiation has been shown to yield equivalent overall survival compared to surgery. D. High-dose radiotherapy to the hemithorax yields significant toxicity.

Back 74

The correct answer is C. The role of radiotherapy in the treatment of malignant pleural mesothelioma (MPM) is limited. While there may be a role as part of multimodality therapy in resectable MPM, there is little role in unresectable disease, as high-dose radiation to the entire hemithorax has NOT shown to improve survival and carries with it signifi cant toxicity. In resected MPM, total adjuvant radiotherapy dose should fall between 50 and 60 Gy, depending on margin status. A retrospective review showed that survival may be dose dependent, with those receiving 40 Gy living longer than those receiving <40 Gy. In those that have undergone pleural intervention, adjuvant radiotherapy to the tract site is recommended . 700 cGy x 3.

Front 75

What hypofractionated radiotherapy regimen yielded no local recurrences in the treated tract sites for malignant pleural mesothelioma as reported by Di Salvo et al.? A. 500 cGy x 3 fractions B. 600 cGy x 3 fractions C. 700 cGy x 3 fractions D. 800 cGy x 3 fractions

Back 75

The correct answer is C. Di Salvo et al. reported their experience of treating the tract sites of 32 patients that had undergone surgery and/or thoracoscopy for diagnosis, staging, or talc pleurodesis. In this retrospective review, at a mean follow-up of 13.6 months, there were no local recurrences after treating the sites with 700 cGy x 3 fractions. RTOG grade 1 toxicity erythema was reported in 11 of the patients.

Front 76

All of the following make malignant pleural mesothelioma unresectable except: A. Contralateral mediastinal involvement B. Multiple pleural plaques in ipsilateral lung C. Diaphragmatic invasion D. Distant spread to brain

Back 76

The correct answer is B. While contralateral mediastinal involvement, diaphragmatic invasion, and distant metastatic disease preclude surgery, the presence of multiple pleural plaques in the ipsilateral lung does not constitute unresectability.