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143 Cards in this Set

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238. Which of the following is the MOST aggressive non-Hodgkin lymphoma?
(A) Mycosis fungoides
(B) Mantle cell lymphoma
(C) Grade I follicular lymphoma
(D) Extranodal marginal zone B-cell lymphoma


Key: B
Rationale: Mantle cell lymphoma is mostly diagnosed as stage IV disease and is known to have moderately aggressive course with median survival around 3 years. Follicular, extranodal marginal zone and mycosis fungoides all have indolent disease course.


284. Which of the following factors is associated with a poor outcome in patients with acute
lymphoblastic leukemia?
A. Age, LDH, peripheral WBC counts at diagnosis, and CNS status
B. Age, LDH, performance status, and rapidity of response to initial chemotherapy
C. Age, WBC count, histologic subtype, cytogenetic test results, and response to
chemotherapy
D. Performance status, peripheral WBC count, fever, and rapidity of response to initial
Chemotherapy


Correct answer is C. RATIONALE: Age, WBC count, acute lymphoblastic leukemia (ALL)
subtype, cytogenetic test results, and response to chemotherapy are known to have the most
significant impact on the outcome of patients diagnosed with ALL. REFERENCE: DeVita, et al.
Principles and Practice of Oncology.


260. A 23-year-old woman with nodular-sclerosing Hodgkin lymphoma has pathologically
enlarged bilateral axillary, right infraclavicular, and left supraclavicular lymph nodes.
She reports having no fever, night sweats, or unexplained weight loss. Which of the
following Ann Arbor stages would be most appropriate for this patient?
A. IA
B. IIA
C. IIIA
D. IVA


Correct answer is B. RATIONALE: Multiple nodal sites are considered to be stage II as long as
they are on the same side of the diaphragm.


30. What was the radiation dose in Gy used in ECOG 1484 (Horning et. al. JCO, 2004) for patients with non-Hodgkin lymphoma in complete response following chemotherapy?
(A) 20
(B) 30
(C) 40
(D) 50

Key: B
Rationale: This trial randomized patients in CR after 8 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) to either 30 Gy involved field RT or no further therapy.

241. Which of the following risk factors is most commonly associated with the development of gastric lymphoma?
(A) Epstein-Barr virus
(B) Human papilloma virus (HPV 16)
(C) Helicobacter pylori
(D) Borrelia burgdorferi

Key: C
Rationale: Helicobacter is well recognized as an associated risk factor in gastric lymphoma. Eradication of Helicobacter pylori with antibiotics often results in resolution of the lymphoma.

186. What is the MOST appropriate treatment for a healthy 55-year-old with a stage IAE marginal zone lymphoma of the stomach?
(A) Total gastrectomy
(B) Radiation therapy to 30 Gy
(C) R-CHOP x 6
(D) R-CHOP x 3 with involved field RT

Key: B
Rationale: RT alone to 30 Gy yields freedom from relapse rates of > 90% and is the standard of care.

211. Which of the following factors MOST accurately predict the outcome of patients with diffuse large B-cell lymphoma?
(A) “B” symptoms, age, sex, extranodal sites, and number of nodal sites
(B) “B” symptoms, age, erythrocyte sedimentation rate, mediastinal bulk, and number of involved sites
(C) “B” symptoms, sex, erythrocyte sedimentation rate, mediastinal bulk, and number of nodal sites
(D) ECOG performance status, age greater than 60 years, LDH, extranodal sites, and stage

Key: D
Rationale: The International Non-Hodgkin's Lymphoma Prognostic Factors Project had outlined the following factors as the most predictive of outcome in patients diagnosed with aggressive non-Hodgkin lymphoma: Age, stage, performance status, extranodal involvement, serum LDH.
References: Project TIN-HsLPF. A predictive model for aggressive non-Hodgkin’s lymphoma. The International Non-Hodgkin’s Lymphoma Prognostic Factors Project. N Engl J Med. 1993; 329:987-994.

165. Chronic lymphocytic leukemia (CLL) differs from small lymphocytic lymphoma (SLL) in that a large number of abnormal lymphocytes are found in the:
(A) CNS.
(B) skin.
(C) lymph nodes.
(D) bone marrow and blood.

Key: D
Rationale: To be able to distinguish CLL from SLL. CLL is confined mainly to blood and bone marrow where SLL in marked by lymphadenopathy.
References: NCCN NHL Guidelines MS-17.

197. What was the involved field radiation therapy dose in Gy used for nodal sites in complete response in EORTC trial 20884 (Aleman et. al. New England Journal of Medicine, 2003) in patients with stage III or IV Hodgkin lymphoma after MOPP-ABV.
(A) 20
(B) 24
(C) 30
(D) 36

Key: B
Rationale: For patients in CR after chemotherapy, 24 Gy was used for nodal sites.

147. Progressive multifocal leukoencephalopathy is MOST often associated with the use of:
(A) ABVD.
(B) CHOP.
(C) Rituximab.
(D) Cetuximab.

Key: C
Rationale: Rituximab carries potentially serious side-effects. Rituximab, an anti CD20 monoclonal antibody, is associated with PML, a fatal infection by the JC virus.
References: NCCN NHL Guidelines MS-14.

277. Radiation therapy alone is the standard treatment for which of the following subtypes of Hodgkin lymphoma?
(A) Lymphocyte depleted
(B) Mixed cellularity
(C) Nodular sclerosis
(D) Nodular lymphocyte predominant

Key: D
Rationale: Nodular lymphocyte predominant Hodgkin’s lymphoma is distinct from the 4 types of Classical Hodgkin’s Lymphoma (nodular sclerosis, mixed cellularity, lymphocyte depleted, and lymphocyte-rich Hodgkin’s lymphoma). It has an indolent course and is effectively treated with involved-field RT alone.

247. What is the standard treatment for a 42-year-old man who has stage IIA nodular
lymphocyte-predominant Hodgkin lymphoma in the left supraclavicular and left axillary
lymph nodes, with the largest node measuring 6.5 cm?
A. ABVD chemotherapy x 6 alone
B. ABVD chemotherapy x 4 and 30 Gy of involved-field radiation therapy
C. Subtotal nodal radiation therapy and involved-field boost to a total dose of 40 Gy
D. Involved-field radiation therapy to a total dose of 36 Gy alone

Correct answer is D. RATIONALE: Nodular lymphocyte-predominant Hodgkin lymphoma is
distinct from the four types of classical Hodgkin lymphoma (nodular sclerosis, mixed cellularity,
lymphocyte depleted, and lymphocyte rich). This distinction is important since nodular
lymphocyte-predominant Hodgkin lymphoma has an excellent prognosis when treated with
involved-field radiation therapy (RT) alone.

234. Autologous stem cell transplantation for patients with relapsed Hodgkin lymphoma has
been shown to:
A. increase a patient’s chances for progression-free survival.
B. increase the toxicity risks, outweighing the treatment benefits.
C. provide no significant benefit compared to radiation alone.
D. be useful only in patients who achieve a complete response to induction
chemotherapy.

Correct answer is A. RATIONALE: Autologous stem cell transplantation (ASCT) has been
proven to be a very important part of a salvage regimen in patients with refractory and relapsed
Hodgkin lymphoma (HL) and is now the generally accepted standard of care for patients with
primary refractory or first-relapsed HL. It has resulted in over 50% of progression-free survival
and superior outcome compared to non-transplantation regimens. REFERENCES: Linch DC,
Winfield D, Goldstone AH, et al. Dose intensification with autologous bone-marrow
transplantation in relapsed and resistant Hodgkin’s disease: Results of a BNLI randomized trial.
Lancet. 1993;341:1051–1054. Schmitz N, Pfistner B, Sextro M, et al. Aggressive conventional
chemotherapy compared with high-dose chemotherapy with autologous hemopoietic stem-cell
transplantation for relapsed chemosensitive Hodgkin’s disease: a randomized trial. Lancet.
2002;359:2065–2071.

193. Which of the following statements most accurately describes grades 1 and 2 follicular
non-Hodgkin lymphoma?
A. Low-dose radiation is ineffective for palliation.
B. Rituximab monotherapy is not a valid approach.
C. Follicular lymphoma is most commonly diagnosed as localized disease.
D. Watchful waiting is a valid approach for asymptomatic disease.

Correct answer is D. RATIONALE: Radiation therapy is very effective in achieving long-term
disease control in targeted areas; however, patients with asymptomatic disease can be safely
observed without affecting their ultimate outcome. Initial response from rituximab treatment
alone is excellent, but not durable. Thus, this drug is usually added to chemotherapy agents or
used during a disease maintenance phase. Follicular lymphoma is mostly commonly diagnosed
at an advanced disease stage. REFERENCES: Jóhannsson J, Specht L, Mejer J, Jensen BA.
Phase II study of palliative low-dose local radiotherapy in disseminated indolent non-Hodgkin's
lymphoma and chronic lymphocytic leukemia. International Journal of Radiation Oncology,
Biology, Physics (Int J Radiat Oncol Biol Phys). 2002 Dec 1;54(5):1466-70. Ardeshna KM,
Smith P, Norton A, et al. British national lymphoma investigation. Long-term effect of a watch
and wait policy versus immediate systemic treatment for asymptomatic advanced-stage non-
Hodgkin lymphoma: a randomized controlled trial. Lancet. 2003;362:516–522. Advani R,
Rosenberg SA, Horning SJ. Stage I and II follicular non-Hodgkin’s lymphoma: long-term followup
of no initial therapy. Journal of Clinical Oncology (J Clin Oncol). 2004;22:1454–1459.

179. A 50-year-old man presents with stage IIB, non-bulky, diffuse, large B-cell non-Hodgkin
lymphoma involving the neck and superior mediastinum. Which of the following
statements about the management of this patient is true?
A. Regardless of treatment, the 5-year overall survival rate is less than 50%.
B. Treatment should include high-dose chemotherapy, followed by autologous stem
cell transplantation.
C. Treatment should include either 8 cycles of R-CHOP or 3 cycles of R-CHOP,
followed by involved-field radiation therapy.
D. R-CHOP for 3 cycles is the best treatment.

Correct answer is C. RATIONALE: This patient presents with aggressive non-Hodgkin
lymphoma (NHL); however, he still has a fair survival probability with either 8 cycles of R-CHOP
or a combination of 3 cycles of R-CHOP and involved-field radiation therapy (IFRT) as
confirmed by randomized data. Rituximab as anti-CD20 targeted agent was found to improve
patients’ outcome. REFERENCES: Horning SJ, Weller E, Kim K, et al. Chemotherapy with or
without radiotherapy in limited-stage diffuse aggressive non-Hodgkin’s lymphoma: Eastern
Cooperative Oncology Group study 1484. Journal of Clinical Oncology (J Clin Oncol). 2004;22:
3032–3038. Miller TP, Spier CM, Rimsza L. Diffuse aggressive histologies of non-Hodgkin
lymphoma: treatment and biology of limited disease. Seminars in Hematology (Semin Hematol).
2006;43:207–212.

176. What is the best management for a 60-year-old woman who has MALT lymphoma of the
right orbit with negative results on systemic workup?
A. Radiation therapy alone to 30 Gy
B. Radiation therapy alone to 45 Gy
C. Chemotherapy alone with R-CHOP
D. Chemotherapy with CHOP, followed by radiation therapy to 30 Gy

Correct answer is A. RATIONALE: Radiation therapy alone to a median dose of 30 Gy will
result in a 99% to 100% local control rate. REFERENCES: Quyn-Thu Le, et al. Primary
radiotherapy for localized orbital malt lymphoma. International Journal of Radiation Oncology,
Biology, Physics (Int J Radiat Oncol Bio Phys). 2002;52(3):657-63. Tsang RW, et al. Journal of
Clinical Oncology (J Clin Oncol). 2003;21(22):4157-64.

173. Precursor T cell lymphoblastic lymphoma most commonly involves the:
A. skin.
B. bone.
C. mediastinum.
D. spleen.

Correct answer is C. RATIONALE: The mediastinum is the most common site of involvement
for precursor T cell lymphoblastic lymphoma. REFERENCE: Tarbell and Weinstein. Non-
Hodgkin lymphoma. Halperin, Constine, Tarbell, Kun (eds). Pediatric Radiation Oncology.
4th ed. pp 261-270.

165. Which of the following trials initially demonstrated an overall survival advantage for
patients who received involved-field radiation therapy in addition to chemotherapy
versus chemotherapy alone for non-Hodgkin lymphoma?
A. ECOG
B. RTOG
C. SWOG
D. CALBG

Correct answer is C. RATIONALE: Only the initial report from the SWOG study showed an
overall survival advantage in patients who received involved-field radiation therapy (RT) in
addition to chemotherapy. The ECOG study demonstrated only a disease-free survival
advantage. The GELA study included patients older that 60 years with good IPI and showed no
advantage to RT. The RTOG has not conducted a non-Hodgkin lymphoma trial with
chemotherapy and radiation therapy. There is no such cooperative group as the “CALBG.” The
organization is the CALGB. REFERENCES: Miller, et al. SWOG study. New England Journal of
Medicine (NEJM). 1998. Horning, et al. ECOG study. Journal of Clinical Oncology (JCO). 2004.
Bonnett, et al. GELA study. Journal of Clinical Oncology (JCO). 2007.

159. Which of the following chromosomal translocations is most likely to be found in patients
with Burkitt's lymphoma?
A. t(2;5)
B. t(8;14)
C. t(11;14)
D. t(14;18)

Correct answer is B. RATIONALE: Chromosomal translocation t(8;14) is observed in Burkitt's
lymphoma. Chromosomal translocation t(2;5) is seen with anaplastic large cell lymphoma,
t(11;14) is seen in multiple myeloma, and t(14;18) is noted in follicular B cell lymphoma.
REFERENCE: Tarbell, Weinstein. Non-Hodgkin lymphoma. Halperin, Constine, Tarbell, Kun
(eds). Pediatric Radiation Oncology. 4th ed. pp 261-270.

151. According to the ECOG 1484 (Horning, et al.) randomized trial, which of the following
involved-field radiation doses was administered to patients who had non-Hodgkin
lymphoma and a partial response to initial chemotherapy?
A. 20 Gy
B. 30 Gy
C. 40 Gy
D. 50 Gy

Correct answer is C. RATIONALE: The ECOG 1484 trial used 40 Gy of involved-field radiation
therapy for patients who had non-Hodgkin lymphoma and a partial response (PR) after 8 cycles
of CHOP chemotherapy. REFERENCE: Horning, et al. Journal of Clinical Oncolog. 2004.

137. Which of the following histological types of primary cutaneous non-Hodgkin lymphoma
has the worst outcome?
A. Follicular
B. Peripheral T-cell
C. Anaplastic large cell
D. Mycosis fungoides

Correct answer is B. RATIONALE: According to large European registry data using WHOEORTC
classification, patients with primary cutaneous peripheral T-cell lymphoma have the
worst disease outcome with a <20% disease-free survival rate at 5 years. REFERENCE:
Willemze R, Jaffe ES, Burg G, Cerroni L, et al. WHO-EORTC classification for cutaneous
lymphomas. Blood. 2005 May 15;105(10):3768-85.

131. Which of the following radiation dose ranges is most appropriate for treatment of a
solitary plasmacytoma?
A. 10 to 15 Gy
B. 25 to 30 Gy
C. 35 to 40 Gy
D. 45 to 50 Gy

Correct answer is D. RATIONALE: The appropriate dose for treating solitary plasmacytoma is
45 to 50 Gy. REFERENCE: DeVita VT, Hellman S, Rosenberg, SA (eds). Cancer: Principles &
Practice of Oncology. 6th ed. Lippincott: 2001; p 2483.

123. What is the most appropriate treatment for patients with Helicobacter pylori negative,
stage IAE gastric MALT non-Hodgkin lymphoma?
A. Total gastrectomy
B. Definitive radiation therapy
C. Multiagent chemotherapy
D. Watchful waiting

Correct answer is B. RATIONALE: Gastric MALT lymphomas are commonly associated with
Helicobacter pylori infection, and if patients are positive for Helicobacter pylori infection,
anti-Helicobacter pylori drugs are the treatment of choice. Untreated disease will eventually
progress, and there is a chance of its transformation to a more aggressive type of disease. In
patients who have persistent disease after Helicobacter pylori treatment or who are negative for
Helicobacter pylori, radiation therapy is a very effective method for achieving a high rate of
disease control. REFERENCE: Tsang RW, Gospodarowicz MK, Pintilie M, et al. Localized
mucosa-associated lymphoid tissue lymphoma treated with radiation therapy has excellent
clinical outcome. Journal of Clinical Oncology (J Clin Oncol). 2003;21:4157–4164.

117. What is the most common site of presentation in a patient with a solitary extramedullary
plasmacytoma?
A. Pelvis
B. Extremities
C. Head and neck
D. Abdomen and thorax

Correct answer is C. RATIONALE: The most common anatomical region for a solitary
extramedullary plasmacytoma is the head and neck area. REFERENCE: Corwin J, Lindberg
RD. Solitary plasmacytoma of bone vs. extramedullary plasmacytoma and their relationship to
multiple myeloma. Cancer. 1979;43:1007-1013.

109. Which of the following treatments would be most appropriate for a 45-year-old woman
with stage IIBX, nodular-sclerosing Hodgkin lymphoma?
A. Two cycles of ABVD chemotherapy alone
B. Four to six cycles of ABVD chemotherapy and involved-field radiation therapy
C. High-dose chemotherapy with autologous stem cell transplantation
D. Extended-field radiation therapy alone

Correct answer is B. RATIONALE: Patients with early-stage, unfavorable Hodgkin lymphoma
can achieve a high cure rate with either multiple cycles of ABVD-like chemotherapy or a
combination of reduced cycles of ABVD (4-6) with involved-field radiation therapy.
Extended-field radiation therapy is effective but is fairly toxic, particularly for long-term
complication risk. High-dose chemotherapy with autologous stem cell transplantation is a very
intense treatment that can cause significant toxicities and is only used in a setting of refractory
or relapsed disease. REFERENCES: Meyer RM, Gospodarowicz MK, Connors JM, et al.
Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy
in patients with limited-stage Hodgkin’s lymphoma: National Cancer Institute of Canada Clinical
Trials Group and the Eastern Cooperative Oncology Group. Journal of Clinical Oncology (J Clin
Oncol). 2005;23(21):4634-4642. Straus DJ, Portlock CS, Qin J, et al. Results of a prospective
randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD)
followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin
disease. Blood. 2004;104(12):3483-3489.

103. Which of the following exams would be best for diagnosis of spinal cord compression in
a patient with multiple myeloma?
A. CT
B. MRI
C. PET
D. Bone scan

Correct answer is B. RATIONALE: An MRI is the best study for diagnosis of spinal cord
compression in patients with multiple myeloma. REFERENCE: Dimopoulos MA, Moulopoulos
LA, Maniatis A, et al. Solitary plasmacytoma of bone and asymptomatic multiple myeloma.
Blood. 2000;96(6):2037-44.

95. According to the ECOG 1484 (Horning, et al.) randomized trial, which of the following
involved-field radiation doses was administered to patients who had non-Hodgkin
lymphoma and a complete response to initial chemotherapy?
A. 20 Gy
B. 30 Gy
C. 40 Gy
D. 50 Gy

Correct answer is B. RATIONALE: The ECOG 1484 trial randomized patients who had non-
Hodgkin lymphoma and a complete response after 8 cycles of CHOP (cyclophosphamide,
doxorubicin, vincristine, and prednisone) chemotherapy to either 30-Gy, involved-field radiation
therapy or no further therapy. REFERENCE: Horning, et al. Journal of Clinical Oncology. 2004.

69. Which of the following diagnostic exams would be best for initial evaluation of a patient
with suspected multiple myeloma?
A. MRI
B. CT scan
C. Bone scan
D. Skeletal survey

Correct answer is D. RATIONALE: A skeletal survey is the best study to quantify lesions in a
patient with multiple myeloma. REFERENCE: DeVita VT, Hellman S, Rosenberg, SA (eds).
Cancer: Principles & Practice of Oncology. 6th ed. Lippincott. 2001; p 2473.

57. Which of the following laboratory abnormalities is most common at presentation in
patients with multiple myeloma?
A. Anemia
B. Thrombocytopenia
C. Lymphocytopenia
D. Neutropenia

Correct answer is A. RATIONALE: Anemia is the most common laboratory abnormality at
presentation in patients with multiple myeloma. REFERENCE: DeVita VT, Hellman S,
Rosenberg, SA (eds). Cancer: Principles & Practice of Oncology. 6th ed. Lippincott: 2001;
p 2471.

21. Which of the following types of leukemia most commonly occurs in children?
A. Acute lymphoblastic
B. Acute myelogenous
C. Chronic myelogenous
D. Chronic lymphocytic

Correct answer is A. RATIONALE: Acute lymphoblastic leukemia is the most common type of
pediatric leukemia, accounting for 75% of cases. Acute lymphoblastic leukemia has a median
age of occurrence of 10 to 12 years. The other disorders have a median age of occurrence in
the 7th decade of life. REFERENCE: Gunderson LL, Tepper JE (eds). Clinical Radiation
Oncology. 2000; p 1089.

138. What is the Ann Arbor stage of Hodgkin disease limited to the right supraclavicular and right cervical regions?
(A) IA
(B) IIA
(C) IIIA
(D) IVA

Key: A
Rationale: The supraclavicular and cervical anatomic regions are considered a single region in the Ann Arbor staging system.

322. What is the most common histologic subtype of non-Hodgkin lymphoma?
A. Mantle cell
B. Diffuse large B-cell
C. Extranodal marginal zone
D. Follicular

Correct answer is B. RATIONALE: Diffuse large B-cell lymphoma is most common and
represents about one third of all non-Hodgkin lymphomas.

318. Which of the following initial management steps would be most appropriate for a patient
with progressive or relapsed Hodgkin disease?
A. Additional chemotherapy
B. Consolidative radiation therapy
C. Stem cell transplant
D. Repeat biopsy

Correct answer is D. RATIONALE: With progressive or relapsed Hodgkin disease, a repeat
biopsy to confirm histology is necessary. REFERENCE: 2009 Practice Guidelines by the
National Comprehensive Cancer Network (NCCN). p 12.

301. What percent of weight loss constitutes a B symptom?
A. 5%
B. 10%
C. 15%
D. 20%

Correct answer is B. RATIONALE: The B symptom of weight loss is defined as 10%.
REFERENCE: 2009 Practice Guidelines by the National Comprehensive Cancer Network
(NCCN). p. 20.

295. Which of the following tests would be best to monitor late effects in a patient after
treatment for Hodgkin lymphoma?
A. PSA serum level and digital rectal exam
B. Aggressive management of cardiovascular risk factors
C. Liver function tests
D. Colonoscopy

Correct answer is B. RATIONALE: Patients treated for Hodgkin lymphoma may be at a higher
risk for cardiovascular events at an earlier onset than patients with non-Hodgkin lymphoma.
REFERENCE: 2009 Practice Guidelines by the National Comprehensive Cancer Network
(NCCN). p 11.

287. A worse prognosis is associated with patients who have chronic lymphocytic leukemia
and deletion of which of the following short-arm chromosomes?
A. 4
B. 8
C. 17
D. 22

Correct answer is C. RATIONALE: Deletion of 17p is an unfavorable feature in chronic
lymphocytic leukemia (CLL). REFERENCE: 2009 Practice Guidelines by the National
Comprehensive Cancer Network (NCCN). p 14.

266. A 43-year-old man presents with stage IA mantle cell lymphoma. Which of the following
radiation doses (in Gy) would be most appropriate?
A. 46
B. 42
C. 36
D. 28

Correct answer is C. RATIONALE: According to the 2009 Practice Guidelines by the National
Comprehensive Cancer Network (NCCN), a radiation dose of 30 to 36 Gy is most appropriate
for early-stage mantle cell lymphoma.

253. Which of the following histologic subtypes of non-Hodgkin lymphoma is CD5 antigen
positive?
A. Mantle
B. Diffuse large cell
C. Marginal
D. Follicular

Correct answer is A. RATIONALE: Mantle non-Hodgkin lymphoma (NHL) is CD5 positive.
Mantle cell lymphoma is thought to represent a variant of follicular lymphoma and was classified
under the Working Formulation as a low-grade lymphoma. Most of the cases of a small-cleaved
cell lymphoma in the Working Formulation terminology were mantle cell lymphomas (MLC).
MLC is a small- to medium-sized B cell lymphoma with irregular nuclei that resemble the
cleaved cells of germinal centers. The morphologic pattern can be diffuse, nodular, or mantle
(mantles of malignant cells around normal-appearing germinal centers) or combinations of any.
mantle cell tumor cells are typically CD5 positive. REFERENCES: Devita, et al. Cancer. 6th
edition. 2001;2220. Halperin EC, Perez CA, Brady LW, eds. Non-Hogkin's lymphoma. Perez
and Brady’s: Principles and Practice of Radiation Oncology. 5th edition. Chapter 76, p. 1742.

238. Which of the following rearrangements is most often associated with follicular
lymphoma?
A. Bcl-2
B. Bcl-16
C. VEGF
D. MALT

Correct answer is A. RATIONALE: Rearrangements of Bcl-2 are often associated with
follicular lymphoma and testing should be considered for diagnosis. REFERENCE: 2009
Practice Guidelines by the National Comprehensive Cancer Network (NCCN). p 22.

210. Which of the following findings is associated with a poor prognosis in children who
present with acute lymphoblastic leukemia?
A. White blood cell count of <50,000/mm3
B. B-cell immunophenotype
C. Chromosomal hyperdiploidy
D. Presence of t(9;22)

Correct answer is D. RATIONALE: Options A-C are favorable features for acute lymphoblastic
leukemia (ALL). The presence of translocation t(9;22) is a high-risk feature associated with a
worse treatment outcome. REFERENCE: Kun L. Leukemias in children. Pediatric Radiation
Oncology. 4th edition. Chapter 2. Philadelphia: Lippincott Williams & Wilkins Publishers. pp 15-
39.

195. Myeloablative therapy for childhood leukemia:
A. is used as consolidative therapy after initial remission in children with acute myeloid
leukemia.
B. is indicated for children who have acute lymphoblastic leukemia without the
Philadelphia chromosome.
C. does not include total body irradiation as part of the bone marrow transplant
conditioning regimen.
D. requires an allogeneic bone marrow transplant.

Correct answer is A. RATIONALE: Myeloablative therapy is indicated in children who have
acute lymphoblastic leukemia (ALL) with the Philadelphia chromosome (BCR-ABL or MLL-AF4).
Cyclophosphamide/TBI as a conditioning regimen is better than busulfan cyclophosphamide for
leukemia control. Both allogeneic and autologous bone marrow transplantations are effective in
treating leukemias. REFERENCE: Kun L. Leukemias in children. Pediatric Radiation Oncology.
4th edition. Chapter 2. Philadelphia: Lippincott Williams & Wilkins Publishers. pp 15-39.

184. Which of the following features is associated with acute lymphoid leukemia?
A. Adult patients treated with an intense chemotherapy regimen can achieve cure rates
as high as those observed in children.
B. A patient’s ability to achieve a complete response after induction chemotherapy is
one of the strongest predictors of disease outcome.
C. High-risk patients who are positive for the Philadelphia chromosome should receive
allogeneic bone marrow transplantation.
D. It is more prevalent than acute myeloid leukemia in the U.S. population.

Correct answer is B. RATIONALE: Acute myeloid leukemia (AML) is more prevalent in the
U.S. population, with 9000 cases per year, when compared with acute lymphoid leukemia (ALL),
with 4000 cases per year. Achieving a complete response after induction chemotherapy is one
of the strongest prognosticators in predicting a patient’s outcome. High-risk patients may benefit
from myeloablative treatment with allogeneic bone marrow transplantation, and TBI is the
preferred conditioning regimen for a superior outcome. REFERENCE: De Vita, et al. Principles
and Practice of Oncology.

180. Which of the following radiation treatments is most appropriate for acute lymphoblastic
leukemia involving the testes?
A. 18 Gy in 10 fractions
B. 24 Gy in 12 fractions
C. 30 Gy in 15 fractions
D. 36 Gy in 18 fractions

Correct answer is B. RATIONALE: Because the testicles are regarded as a sanctuary site,
testicular radiation therapy to a dose of 20-24 Gy in 2-Gy fractions is given as a consolidative
therapy after chemotherapy. REFERENCES: Hustu HO, et al. Extramedullary leukemia.
Clinical Haematology (Clin Haematol). 1978;7(2):313-337. Bowman WP, et al. Isolated
testicular relapse in acute lymphocytic leukemia of childhood: categories and influence on
survival. Journal of Clinical Oncology. Aug 1984;2(8):924-9. Kun L. Leukemias in children.
Pediatric Radiation Oncology. 4th edition. Chapter 2. Philadelphia: Lippincott Williams & Wilkins
Publishers. pp 15-39.

158. Which of the following management options would be best to recommend for a patient
with conjunctival follicular lymphoma?
A. Rituximab for 6 months
B. Involved-field radiation therapy of 25 to 35 Gy
C. Combined multiagent chemotherapy and involved-field radiation therapy
D. Orbital radiation therapy of 35 to 45 Gy

Correct answer is B. RATIONALE: Conjunctival follicular lymphoma is a highly curable disease
and can be treated effectively with conformal techniques. There is no dose response above 30
Gy. Rituximab can yield an initial good response; however, it may not be durable. Proper
imaging with MRI is reliable in ruling out disease involvement beyond anterior structures.
REFERENCE: Halperin EC, Perez CA, Brady LW, eds. Perez and Brady’s: Principles and
Practice of Radiation Oncology. 5th edition. pp 793, 1752.

142. A 70-year-old woman has grade 1 follicular lymphoma involving the pelvic lymph nodes.
Which of the following management options would be most appropriate for this patient?
A. Rituximab for 6 months
B. Radiation therapy to 40 Gy
C. Either observation or radiation therapy of 20 to 30 Gy
D. Combined multiagent chemotherapy and involved-field radiation therapy

Correct answer is C. RATIONALE: Patients with low-grade follicular lymphoma have several
options for disease management: observation, radiation therapy, and chemotherapy provide an
equal chance of survival for this patient. REFERENCE: Horning ST. Natural history of and
therapy for the indolent non-Hodgkin lymphomas. Seminars in Oncology (Semin Oncol).
1993;20:75-80.

112. A 65-year-old man with stage IIB diffuse large B-cell lymphoma has a 10-cm mediastinal
mass, an LDH serum level of 300 U/L, and an erythrocyte sedimentation rate (ESR) of
50 mm/h. His ECOG performance status is 2. Which of the following factors is
associated with the worst prognosis?
A. Staging, B symptoms
B. High ESR, B symptoms
C. Bulky disease, high ESR
D. Performance status, high LDH level

Correct answer is D. RATIONALE: International Non-Hodgkin’s Lymphoma Prognostic Factors
include an age of >60 years, stage III/IV disease, elevated lactate dehydrogenase (LDH) serum
level, Eastern Cooperative Oncology Group (ECOG) performance status ≥2, more than one
extranodal site of disease. REFERENCE: Project TIN-HsLPF. A predictive model for aggressive
non-Hodgkin lymphoma. The International Non-Hodgkin’s Lymphoma Prognostic Factors
Project. New England Journal of Medicine (NEJM). 1993;329:987-994.

97. According to the EORTC 20884 (Aleman) trial, what involved-field radiation dose (in Gy)
was delivered to the lymph node sites in patients who had a complete response to
MOPP-ABV chemotherapy for stage III or IV Hodgkin lymphoma?
A. 20
B. 24
C. 30
D. 36

Correct answer is B and C. RATIONALE: For patients who had a complete response to
chemotherapy, a radiation dose of 24 Gy or 30 Gy was delivered to the lymph node sites.
REFERENCE: Aleman, et al. New England Journal of Medicine (NEJM). 2003.

73. Which of the following Ann Arbor stages is most appropriate for a patient who has
Hodgkin lymphoma with enlarged lymph nodes in the preauricular, cervical, and
supraclavicular regions, but no other adenopathy on workup?
A. IA
B. IAE
C. IIA
D. IIIA

Correct answer is A. RATIONALE: The preauricular, cervical, and supraclavicular lymph node
regions are considered as one region, based on the Ann Arbor staging system.

60. Which of the following histologic subtypes of Hodgkin lymphoma has the best prognosis
after treatment with involved-field radiation therapy alone?
A. Lymphocyte-depleted
B. Nodular lymphocyte-predominant
C. Nodular sclerosis
D. Mixed cellularity

Correct answer is B. RATIONALE: Nodular lymphocyte-predominant Hodgkin lymphoma is
distinct from the 4 types of classical Hodgkin lymphoma (nodular sclerosis, mixed cellularity,
lymphocyte-depleted, and lymphocyte-rich Hodgkin lymphoma). This distinction is important
since nodular lymphocyte-predominant Hodgkin lymphoma has an excellent prognosis when
treated with involved-field radiation therapy alone.

44. An otherwise healthy 50-year-old patient is diagnosed with stage IAE, extranodal
marginal zone lymphoma of the stomach. Which of the following treatments would be
most appropriate for this patient?
A. Total gastrectomy
B. R-CHOP x 3 and involved-field radiation therapy to 40 Gy
C. R-CHOP x 6 and involved-field radiation therapy to 30 Gy
D. Radiation therapy alone to 30 Gy

Correct answer is D. RATIONALE: Radiation therapy alone to 30 Gy is the standard of care
and yields relapse-free rates of >90%.

30. Which of the following studies reported a statistically significant improvement in overall
survival for patients receiving chemotherapy plus involved-field radiation therapy versus
chemotherapy alone for early-stage, aggressive non-Hodgkin lymphoma?
A. SWOG (Miller)
B. ECOG (Horning)
C. GELA (Bonnet)
D. EORTC (Gilman)

Correct answer is A. RATIONALE: Only the initial report from the SWOG study showed an
overall survival advantage for the addition of involved-field radiation therapy (RT) to
chemotherapy. The ECOG study demonstrated only a disease-free survival advantage. The
GELA study included patients older than 60 years with good IPI, and it showed no benefit from
the use of RT. REFERENCES: Miller, et al. SWOG study. New England Journal of Medicine
(NEJM). 1998. Horning, et al. ECOG study. Journal of Clinical Oncology (JCO). 2004. Bonnet,
et al. GELA study. Journal of Clinical Oncology (JCO). 2007.

356. Unlike most small lymphocytic lymphomas, MALT lymphomas are associated with
negative test results for which of the following immunophenotypic markers?
A. CD5
B. CD19
C. CD20
D. CD21

Answer 356 is A. Unlike most small lymphocytic lymphomas, MALT lymphomas are
distinctive morphologically, phenotypically and clinically and are CD5 negative.

359. Which of the following adverse effects is most commonly associated with the
administration of CHOP chemotherapy?
A. Foreshortened limbs
B. Red man syndrome
C. Pulmonary toxicity
D. Cardiotoxicity

Answer 359 is D. Of the above choices, cardiac toxicity is most often associated with the
administration of CHOP due to the doxorubicin.

83. Which of the following is the MOST accurate description of early-stage nodular lymphocyte predominant Hodgkin lymphoma in adults?
(A) It most commonly affects extranodal sites.
(B) It is CD20+ and Rituximab alone will achieve a high cure rate.
(C) Multi-agent chemotherapy is the treatment of choice.
(D) Involved-field radiotherapy is the treatment of choice.

Key: A, D
Rationale: Disease commonly presents in supradiaphragmatic sites and spares mediastinum. In most studies, radiotherapy (RT) as a single-modality therapy was used primarily in limited stage disease, whereas chemotherapy was reserved mostly for advanced stage disease; few patients were treated with chemotherapy alone.
References: GP, Mauch P: What is the appropriate systemic chemotherapy for lymphocyte-predominant Hodgkin's lymphoma? J Clin Oncol (2010) ; Regula DP Jr., Hoppe RT, Weiss LM. Nodular and diffuse types of lymphocyte predominance Hodgkin's disease. N Engl J Med1988;318:214-219; Sextro M, Diehl V, Franklin J, et al. Lymphocyte predominant Hodgkin's disease - a workshop report. European Task Force on Lymphoma.

84. What is the standard treatment for a stage IAE marginal zone lymphoma of the orbit?
(A) 30 Gy only
(B) R-CHOP x 6 only
(C) R-CHOP x 6 and 30 Gy
(D) R-CHOP x 3 and 40 Gy

Key: A
Rationale: 30 Gy involved field RT has a local control of > 90% and is the standard of care.

364. Which of the following chemotherapy regimens is NOT one of the treatment arms in the
German Hodgkin Study Group (HD 9) prospectively randomized trial on advanced
Hodgkin disease?
A. MOPP-ABV
B. COPP-ABVD
C. Standard BEACOPP
D. Dose-increased BEACOPP

Answer 364 is A. It was a 3-arm trial comparing COPP-ABVD, standard BEACOPP and dose increased BEACOPP.

367. Which of the following drugs is NOT part of the Stanford V chemotherapy regimen?
A. Vinblastine
B. Dacarbazine
C. Mechlorethamine
D. Etoposide

Answer 367 is B. The drugs in the Stanford V regimen are: Mechlorethamine, Doxorubicin,
Vinblastine, Vincristine, Bleomycin and Prednisone.

374. Which of the following findings is most commonly associated with patients who present
with chronic lymphocytic leukemia?
A. Anemia
B. Splenomegaly
C. Hepatomegaly
D. Lymphadenopathy

Answer 374 is D. Eighty-five to 90% of patients with CLL present with peripheral
lymphadenopathy.

55. Which of the following BEST describes the role of autologous stem cell transplantation (ASCT) in patients with Hodgkin lymphoma?
(A) Toxicity risks outweigh the benefit with relapsed or refractory disease.
(B) It is an effective treatment for relapsed disease.
(C) It is used in patients who have achieved partial response to induction chemotherapy.
(D) It is used in patients over 70 years old.

Key: B
Rationale: ASCT is proven to be very important part of salvage regimen in patients with refractory and relapsed Hodgkin’s lymphoma and is now the generally accepted standard of care for patients with primary refractory or first-relapsed HL. It gives them over 50% of progression-free survival and superior outcome compared to non-transplantation regimens.
References: Linch DC, Winfield D, Goldstone AH et al. Dose intensification with autologous bone-marrow transplantation in relapsed and resistant Hodgkin’s disease: Results of a BNLI randomised trial. Lancet 1993; 341:1051-1054. Schmitz N, Pfistner B, SextroMet al. Aggressive conventional chemotherapy compared with high-dose chemotherapy with autologous haemopoietic stem-cell transplantation for relapsed chem.

12. Which of the following chromosomal translocations is most commonly associated with Burkitt lymphoma?
A. t(8;14)
B. t(9;22)
C. t(11;14)
D. t(14;18)

Correct answer is A. RATIONALE: Option B is the correct answer for chronic myelogenous leukemia (CML), option C is for mantle cell lymphoma, and option D is for follicular lymphoma.

35. Which of the following antigens is a T-cell marker?
A. CD7
B. CD20
C. CD30
D. CD40

THIS ITEM WAS NOT SCORED. RATIONALE: T-cell lineage is evident from the presence of T-cell markers (CD3, CD2, and CD7).

38. According to the National Comprehensive Cancer Network (NCCN) guidelines, which of the following radiation dose ranges would be most appropriate for treatment of intermediate-grade non-Hodgkin lymphoma?
A. 10 Gy to 15 Gy
B. 30 Gy to 40 Gy
C. 50 Gy to 55 Gy
D. 60 Gy to 70 Gy

Correct answer is B. RATIONALE: National Comprehensive Cancer Network (NCCN) guidelines specify 30 Gy to 36 Gy or 40 Gy in the case of bulky disease.

11. Which of the following is TRUE for adult patients treated with radiotherapy for an early stage favorable Hodgkin lymphoma?
(A) It is most beneficial for patients who achieve only partial response to chemotherapy.
(B) Extended field is best for local control.
(C) It no longer has a role in treatment due to high response to chemotherapy.
(D) The cumulative dose is 45 Gy regardless of chemotherapy response.

Key: A
Rationale: Combination of multi-agent chemotherapy like ABVD followed by lower dose involved-field radiotherapy (20-30 Gy) achieves the best outcome in patients with early stage Hodgkin lymphoma.
References: Engert A et al, N Eng J Med 2010; 363: 640-52 Eich HT et al, JCO 2010; 28: 4199-206.

51. Which of the following factors is included in the international prognostic index (IPI) for non-Hodgkin lymphoma?
A. Histology
B. Weight loss
C. Lactate dehydrogenase (LDH) level
D. Erythrocyte sedimentation rate (ESR)

Correct answer is C. RATIONALE: The international prognostic index (IPI) consists of stage, age, performance status, LDH, and number of extranodal sites.

63. CHOP chemotherapy contains which of the following drugs?
A. Vinblastine
B. Hydroxyurea
C. Prednisone
D. Carmustine

Correct answer is C. RATIONALE: CHOP chemotherapy includes cyclophosphamide, doxorubicin, Oncovin, and prednisone.

75. Which of the following histologies is most likely to be associated with primary CNS lymphoma?
A. Burkitt
B. Follicular
C. Hodgkin disease
D. Diffuse large B-cell

Correct answer is D. RATIONALE: Most primary CNS lymphomas are diffuse large B-cell, immunoblastic or lymphoblastic lymphomas.

103. What is a major criterion for the diagnosis of multiple myeloma?
A. Calcium level of >12 mg/dL
B. Hemoglobin level of 8.5 g/dL
C. Plasmacytoma on tissue biopsy
D. Lytic bone lesions on skeletal survey

Correct answer is C. RATIONALE: Major criteria are plasmacytoma on tissue biopsy, bone marrow plasmacytoses of >30% plasma cells, and elevated monoclonal globulin spike on serum electrophoresis above a defined level.

115. Which of the following radiation dose ranges is most commonly used to treat solitary plasmacytoma?
A. 15 Gy to 20 Gy
B. 24 Gy to 30 Gy
C. 40 Gy to 50 Gy
D. 60 Gy to 70 Gy

Correct answer is C. RATIONALE: Dose response data indicate that 40 Gy to 50 Gy will control most solitary plasmacytomas.

131. Which of the following factors is most strongly linked to an increased risk for the development of multiple myeloma?
A. Alcohol use
B. Tobacco use
C. Mustard gas exposure
D. Ionizing radiation exposure

Correct answer is D. RATIONALE: Ionizing radiation exposure is a risk factor for multiple myeloma, as shown by a marked increase of this tumor in Hiroshima survivors.

132. Which of the following types of acute leukemia occurs most commonly during childhood?
A. Pre-B cell lymphocytic
B. Mature B-cell lymphocytic
C. Mature T-cell lymphocytic
D. Monocytic myelogenous

Correct answer is A. RATIONALE: This item is based on the epidemiology of childhood leukemia. Acute lymphocytic leukemia (ALL) comprises 80% of all acute leukemias in childhood. Most are the pre-B cell type.

146. Which of the following anatomical sites is most commonly associated with extraosseous, soft tissue plasmacytomas?
A. Back
B. Pelvis
C. Lower extremity
D. Head and neck

Correct answer is D. RATIONALE: Extramedullary plasmacytomas arise most frequently in the head and neck and upper respiratory tract.

147. Which of the following types of acute leukemia is most likely to be associated with a 12-year-old boy who presents with a large mediastinal mass and lymphoblasts in his blood?
A. Pre-B cell lymphocytic
B. Mature B-cell lymphocytic
C. Mature T-cell lymphocytic
D. Monocytic myelogenous

Correct answer is C. RATIONALE: This item is based on the epidemiology of childhood leukemia. This is a classic presentation of mature T-cell lymphocytic leukemia (older boy with a mediastinal mass).

150. Which of the following cell markers is most commonly associated with classic Hodgkin lymphoma?
A. CD15+, CD30+
B. CD15+, CD30-
C. CD15-, CD30+
D. CD15-, CD30-

Correct answer is A. RATIONALE: Classical Hodgkin lymphoma has cell markers CD15+, CD30+, and can be CD20+ or CD20-. A is the only possible answer.

89. Approximately what percent of patients who have follicular non-Hodgkin lymphomas present with B symptoms?
A. 75%
B. 50%
C. 25%
D. 05%

Correct answer is D. RATIONALE: B symptoms occur very infrequently in non-Hodgkin lymphoma and usually are associated with stage III or IV disease.

162. Which of the following factors is associated with a higher risk for the development of Hodgkin lymphoma in economically developed countries?
A. Early birth order
B. Increased number of siblings
C. Increased number of playmates as child
D. Chronic immunosuppressant treatment

Correct answer is A. RATIONALE: Hodgkin lymphoma has been found to be related to the level of maternal education for younger patients, decreased number of playmates, decreased number of siblings, and early birth order in economically developed countries.

192. Hodgkin lymphoma most commonly occurs during which decade of life?
A. Second
B. Third
C. Fourth
D. Fifth

Correct answer is B. RATIONALE: The majority of Hodgkin lymphoma cases occur during the third decade (20 to 30 years of age). The incidence is bimodal, though, with a second peak in incidence (although much smaller) after 50 years of age or in the sixth decade onward.

212. A 22-year-old man with Hodgkin disease has adenopathy of the right cervical and right supraclavicular regions and weight loss of >10% of his baseline body weight. Which of the following cancer stages is most likely to be associated with this patient's condition?
A. Stage IA
B. Stage IB
C. Stage IIA
D. Stage IIB

Correct answer is B. RATIONALE: The patient has significant weight loss and night sweats, both of which qualify as "B" symptoms. The cervical and supraclavicular lymph node chains are considered a unified area for the purpose of staging and management. Hence, the patient has cancer stage IB.

222. Which of the following radiation doses were compared in the randomized treatment arms of the German Hodgkin Study Group, HD 10 trial of patients with early-stage disease?
A. 36 Gy vs. 40 Gy
B. 24 Gy vs. 36 Gy
C. 20 Gy vs. 30 Gy
D. 00 Gy vs. 20 Gy

Correct answer is C. RATIONALE: The randomization of radiation therapy is 20 Gy vs. 30 Gy, which followed a randomization of 2 versus 4 cycles of ABVD systemic therapy.

238. Which of the following Hodgkin lymphoma subtypes is most closely associated with the development of non-Hodgkin lymphoma?
A. Nodular sclerosis
B. Lymphocyte depleted
C. Lymphocyte predominant
D. Lymphocyte rich

Correct answer is C. RATIONALE: Compared to other subtypes, there is a documented association between lymphocyte-predominant Hodgkin lymphoma and non-Hodgkin lymphoma. The risk is thought to be approximately 3% (relative risk of 1.8), and the risk is presumed to be independent of therapy.

258. Which of the following lymph node chains is most commonly involved in patients who present with Hodgkin lymphoma?
A. Inguinal
B. Paraaortic
C. Mediastinal
D. Cervical

Correct answer is D. RATIONALE: Approximately 60% to 80% of patients with Hodgkin lymphoma present with cervical/supraclavicular adenopathy. Approximately 50% of patients have mediastinal lymph node involvement.

276. Which of the following factors increases a patient's risk for the development of leukemia?
A. Occupational exposure to benzene
B. Occupational exposure to aluminum
C. Use of mitomycin C
D. Exposure to HPV

Correct answer is A. RATIONALE: Risk factors for leukemia include radiation exposure/atomic bomb experience, smoking, and benzene exposure. There has been no established relationship to viral exposure with HPV, mitomycin C, aluminum, or thalidomide.

296. Which of the following factors is associated with chronic myelogenous leukemia?
A. t(5;17)
B. t(9;22)
C. Trisomy 8
D. Trisomy 21

Correct answer is B. RATIONALE: The chromosomal translocation t(9;22) is called the "Philadelphia (Ph) chromosome," and translocation of the BCR and ABL genes are present in approximately 90% of chronic myelogenous leukemia (CML) cases.

316. Which of the following types of leukemia has the highest risk of CNS involvement?
A. Acute lymphocytic
B. Acute myelogenous
C. Chronic myelogenous
D. Chronic lymphocytic

Correct answer is A. RATIONALE: The eye/ocular region, testicles, and central nervous system (CNS) are common sanctuary sites in acute lymphocytic leukemia (ALL), with the CNS being the most common. Because of this, CNS prophylaxis is often employed.

327. Which of the following types of leukemia is associated with myeloperoxidase activity and cell markers CD13 and CD33?
A. Acute lymphocytic
B. Acute myelogenous
C. Chronic myelogenous
D. Chronic lymphocytic

Correct answer is B. RATIONALE: Myeloperoxidase activity and cell markers CD13 and CD33 are related to acute myelogenous leukemia (AML). Cell markers CD2, CD5, and CD7 are related to T-cell acute lymphocytic leukemia (ALL), and CD10, CD19, and CD22 are related to B-cell ALL.

352. Which of the following types of leukemia has the highest incidence rate?
A. Acute lymphocytic
B. Acute myelogenous
C. Chronic myelogenous
D. Chronic lymphocytic

Correct answer is D. RATIONALE: Chronic lymphocytic leukemia (CLL) is approximately twice as common in men as in women and is more common than other leukemias.

160. Approximately what percent of pediatric patients with Hodgkin lymphoma present with stage IV disease?
(A) 5%
(B) 20%
(C) 35%
(D) 50%

Key: B
Rationale: Handbook of Evidence-Based Radiation Oncology. Hansen and Roach editors.

2. Which of the following translocations is associated with mantle cell lymphoma?
A. t(8;14)
B. t(11;14)
C. t(11;18)
D. t(14;18)

Correct answer is B. RATIONALE: T(11;14) is an established translocation associated with mantle cell lymphoma.

11. According to the GELA study, the use of CHOP plus radiation therapy compared to
CHOP alone for patients older than 60 years of age with stage I and stage II
non-Hodgkin's lymphoma resulted in:
A. a higher percentage of treatment-related death.
B. a significant improvement in event-free survival.
C. a significant improvement in overall survival.
D. no significant difference in overall survival.

Correct answer is D. RATIONALE: There was no significant difference in overall survival (OS) or event-free survival (EFS) in the GELA study. Reference: Journal of Clinical Oncology. 2007;25:787-792.

14. The international prognostic index (IPI) for non-Hodgkin's lymphoma includes which of
the following patient criteria?
A. Age
B. Fever
C. Weight
D. Pruritus

Correct answer is A. RATIONALE: The international prognostic index (IPI) for non-Hodgkin’s lymphoma includes lactic dehydrogenase (LDH) level, involvement of extranodal sites, age, performance status (ECOG), and cancer stage.

40. A bone marrow biopsy would be most appropriate for which of the following clinical
stages in patients with Hodgkin's lymphoma?
A. IA
B. IIA
C. IIB
D. IIIC

Correct answer is C. RATIONALE: Bone marrow biopsy is recommended in patients who have clinical stages IB-IIB and III and IV Hodgkin’s lymphoma.

45. Which of the following is NOT a histological subtype of Hodgkin's lymphoma?
A. Mixed cellularity
B. Mixed sclerosis
C. Nodular sclerosis
D. Lymphocyte depleted

Correct answer is B. RATIONALE: Mixed sclerosis is not a histological subtype of Hodgkin’s lymphoma.

62. Which of the following risk factors is most commonly associated with the development of
gastric lymphoma?
A. Epstein-Barr virus
B. Human papilloma virus (HPV 16)
C. Helicobacter pylori
D. Borrelia burgdorferi

Correct answer is C. RATIONALE: Helicobacter is well recognized as an associated risk factor in gastric lymphoma. Eradication of Helicobacter pylori with antibiotics often results in resolution of the lymphoma.

68. Which of the following statements about chronic lymphocytic leukemia (CLL) in adults is
true?
A. The median age at diagnosis is 30 years.
B. It occurs less frequently than acute lymphocytic leukemia (ALL).
C. More than 50% of patients will develop a more aggressive lymphoid malignancy.
D. The prognosis is primarily determined by the disease stage.

Correct answer: ABCD. RATIONALE: Staging systems (such as Rai and Binet) are commonly used to determine the extent of sites of disease involvement and severity of hematological abnormalities, which determine the prognosis and overall survival of patients with chronic lymphocytic leukemia (CLL). Patients with CLL usually present at an older age (median age of 60 years old). CLL is more common than acute lymphocytic leukemia (ALL) in adults. About 5% to 15% of CLL will evolve into a more aggressive lymphoid malignancy.

80. Which of the following agents is NOT included in the ABVD chemotherapy regimen?
A. Bleomycin
B. Doxorubicin
C. Vinblastine
D. Dexamethasone

Correct answer is D. RATIONALE: Dexamethasone is not an agent in ABVD chemotherapy. All of the other options as well as dacarbazine are agents in the ABVM chemotherapy regimen.

85. Which of the following special precautions should be used when treating a patient with
total skin electron irradiation?
A. A large Lucite screen to reduce the skin dose
B. Dual electron beams angled 20o off of the central axis to reduce the x-ray
contamination
C. High-energy electrons (19 MeV) to ensure the appropriate depth of penetration
D. Custom blocks designed to minimize the lung dose

Correct answer is B. RATIONALE: This question requires knowledge of the American
Association of Physicists in Medicine Task Group 30 (AAPM TG30) report. Option A is false, since the screen acts to degrade the energy of the incident beam, thereby shifting the PDD to produce a shallower depth dose, and a higher skin dose. Option C is false, since typical treatment energies range from 4 to 10 MeV, according to the AAPM TG30 report. Option D is false, since lung blocks are typically used when treating a patient with total-body photon irradiation. Since electrons have a rapid dose falloff beyond dmax, lung blocks are not necessary when treating a patient with total skin electron irradiation.

92. According to the Chronic Leukemia-Myeloma Task Force, which of the following findings
is required for a diagnosis of plasma cell myeloma in patients who have normal
paraimmunoglobulin findings and radiographic evidence of osteolytic lesions with
palpable tumors?
A. WBC count of 15,000 cells/mL in the absence of other disease capable of causing
reactive leukocytosis
B. Marrow plasmacytosis of 20% in absence of other disease capable of causing
reactive plasmacytosis
C. Hemoglobin value of 10 mg/dL
D. Plasma blood level of 500 cells/mL

Correct answer is B. RATIONALE: Since a number of patients with plasma cell neoplasms present without paraimmunoglobulinopathy, it is important to know the criteria for establishing a diagnosis for this group of patients. According to the Chronic Leukemia-Myeloma Task Force guidelines, there has to be a marrow plasmacytosis greater than 20% in absence of other disease capable of causing reactive plasmacytosis in addition to paraimmunoglobulinopathy to meet the criteria of plasma cell neoplasm.

112. Which of the following patient factors is associated with a poorer prognosis for adults
diagnosed with acute myelogenous leukemia?
A. Age of 55 years
B. WBC count of 100,000 cells/mL
C. History of myelodysplastic syndrome
D. Positive results for Philadelphia chromosome

Correct answer is C. RATIONALE: There several negative prognostic factors for patients with acute myelogenous leukemia (AML): older age, certain cytogenetic abnormalities, and the presence of antecedent hematological disorders. Myelodysplastic syndrome has been shown to be associated with a poorer outcome. The Philadelphia chromosome is more commonly present in patients with chronic myelogenous leukemia (CML) and acute lymphocytic leukemia (ALL), and it is not considered a prognostic factor for AML.

114. A 42-year-old man presents with a 5-cm, raised, erythematous skin nodule overlying the
deltoid muscle. The lesion is slightly painful at times. Biopsy reveals marginal zone
lymphoma. The patient's 5-year relative survival rate is approximately:
A. 20%.
B. 45%.
C. 70%.
D. 95%.

Correct answer is D. RATIONALE: This represents a low-grade lymphoma of the skin and is in the favorable prognostic index (PI) group IA. The 5-year relative survival is 94% regardless of the therapy chosen. Reference: Smith, et al. Journal of Clinical Oncology. 2005;23:3390-3395.

125. Which of the following genetic abnormalities is most commonly associated with chronic myelogenous leukemia?
A. t(8;14)
B. t(9;22)
C. t(11;22)
D. Trisomy 8

Correct answer is B. RATIONALE: More than 90% of patients with chronic myelogenous leukemia (CML) have the Philadelphia chromosome with t(9;22).

131. A 70-year-old woman has a stage IAE conjunctival, marginal zone, B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma. Which of the following radiation therapy approaches is most appropriate for this patient?
A. Local fractionated radiation therapy with a final dose of 55 Gy
B. Local fractionated radiation therapy with a final dose of 30 Gy
C. Bilateral orbital fractionated radiation therapy to 30 Gy
D. Craniospinal irradiation to 23.4 Gy, followed by a boost dose to 45 Gy

Correct answer is B. RATIONALE: Moderate doses of radiation therapy alone can provide excellent local control and cause specific survival outcomes (>90% at 10 years) in early-stage MALT lymphoma. It is not necessary to treat large fields or to use high doses. The role of chemotherapy vs. radiation therapy is controversial.

136. What is the approximate annual risk that a patient who received radiation therapy for Hodgkin's lymphoma will have a second solid malignancy with non-breast histology after a latency period of 15 years?
A. 12%
B. 05%
C. 01%
D. 00.01%

Correct answer is C. RATIONALE: In general, the risk of a non-breast histology, second solid malignancy after radiation therapy for Hodgkin's lymphoma is roughly 0.9% per year after a latency period.

88. For patients with non-Hodgkin lymphoma, what report demonstrated an overall survival advantage of adding involved-field RT to chemotherapy compared to chemotherapy alone?
(A) ECOG (Horning et. al. JCO, 2004)
(B) GELA (Bonnett et. al. JCO, 2007)
(C) SWOG (Miller et. al. NEJM, 1998)
(D) EORTC (Aleman, NEJM 2003)

Key: C
Rationale: Only the initial report from the SWOG study showed an overall survival advantage for the addition of involved field RT to chemotherapy. The ECOG study demonstrated only a disease free survival advantage. The GELA study included patients older than 60 years with good IPI and showed no advantage to RT. EORTC 20884 referred to Hodgkin lymphoma.

141. Which of the following statements about solitary plasmacytoma is most appropriate?
A. A radiation dose of ≤30 Gy provides excellent local control.
B. Adding chemotherapy after radiation therapy has not been shown to improve
survival.
C. The majority of patients will progress to multiple myeloma within 3 years after initial
presentation.
D. Patients with solitary plasmacytoma of the bone are at low risk for the development
of multiple myeloma.

Correct answer is B. RATIONALE: Chemotherapy has failed to show an improved outcome for patients with solitary plasma cell malignancy. Usually radiation doses in the range of 40 to 50 Gy are necessary to achieve high local control for solitary plasmacytomas. The majority of patients with solitary plasmacytoma will progress to multiple myeloma after >5 years, based on most reports. Patients with solitary bone plasmacytoma have a much higher chance of developing multiple myeloma compared to patients with extramedullary solitary plasmacytomas.

164. A 32-year-old man with clinical stage IA nodular sclerosis Hodgkin's lymphoma of the right axilla receives 4 cycles of chemotherapy and experiences a complete response.
What would be the most appropriate dose of adjuvant radiation therapy?
A. 40 Gy
B. 30.6 Gy
C. 18 Gy
D. No radiation therapy is required.

Correct answer is B. RATIONALE: The most appropriate dose of radiation therapy is 30.6 Gy for a patient who has early-stage nodular sclerosis Hodgkin’s lymphoma with no adverse risk factors and has had a complete response to multiagent chemotherapy.

167. A 52-year-old patient with a 3-cm, stage IA large cell lymphoma in the left neck has a complete response to 3 cycles of CHOP chemotherapy based on PET/CT scans. Which of the following involved fields would be most appropriate to treat with radiation therapy?
A. Bilateral neck only
B. Bilateral neck and left supraclavicular region
C. Left neck, left supraclavicular region, and upper mediastinum
D. Left neck and left supraclavicular region only

Correct answer is D. RATIONALE: The left neck and left supraclavicular regions are
considered the appropriate involved-field region for the radiation therapy portal. Reference: Yahalom and Mauch. Annals of Oncology. 2002.

197. A 72-year-old man presents with a 6-cm painful mass in the right inguinal region. Biopsy and staging reveal grade 1 follicular lymphoma, stage 1A. What is the most appropriate treatment for this patient?
A. Radiation therapy alone
B. Radiation therapy, followed by CHOP chemotherapy
C. CHOP chemotherapy, followed by involved-field radiation therapy
D. Observation

Correct answer is A. RATIONALE: The patient will have an excellent response to radiation therapy alone and may experience durable local control. He has a high risk of failure outside of the radiation therapy (RT) port, but there is no survival benefit to the addition of systemic therapy either as an adjuvant to RT or before RT.

222. Extramedullary plasmacytomas most commonly occur in which of the following
locations?
A. Lower extremity
B. Paraspinal musculature
C. Head and neck
D. Rectum

Correct answer is C. RATIONALE: Approximately 80% of extramedullary plasmacytomas occur in the upper aero-digestive tract.

246. For Hodgkin's or non-Hodgkin's lymphoma, complete response unconfirmed (CRu) is best defined as tumor shrinkage of:
A. ≤1.0 cm when the initial mass was 1.1 to 1.5 cm with negative functional imaging.
B. ≤1.5 cm when the initial mass was 1.5 cm with negative functional imaging.
C. 75% when the initial mass was 1.5 cm with negative functional imaging.
D. 50% with failure to convert on functional imaging.

Correct answer is C. RATIONALE: Options A and B define a complete response (CR), and option D defines no response (NR). Option C is the definition of a CRu.

260. Which of the following diseases does NOT belong to the family of plasma cell
neoplasms?
A. Plasma cell leukemia
B. Plasma cell granuloma
C. Monoclonal gammopathy of unknown significance
D. Extraskeletal plasmacytoma

Correct answer is B. RATIONALE: Knowledge of disease entities belonging to malignant plasma cell neoplasms is important when making decisions regarding their management.

266. According to the EORTC, which of the following patient characteristics is a favorable risk factor for Hodgkin's lymphoma?
A. Age of <40 years
B. ESR of >50 mm/hr
C. ESR of >30 mm/hr with B symptoms
D. Four or more sites of disease

Correct answer is A. RATIONALE: An age of >50 years is an unfavorable risk factor for
Hodgkin’s lymphoma, according to the prognostic groups as defined by the European
Organization for Research and Treatment of Cancer (EORTC).

268. Lymphocyte-predominant Hodgkin's disease consistently expresses high levels of what B-cell marker antigen?
A. CD4
B. CD15
C. CD20
D. CD30

Correct answer is C. RATIONALE: Lymphocyte-predominant Hodgkin’s disease, unlike the other 4 histological subtypes of Hodgkin's disease (nodular sclerosis, mixed-cellularity, lymphocyte-depleted, and lymphocyte-rich), which are CD15+ and CD30+, consistently expresses CD20.

291. What is the approximate risk that acute lymphoblastic leukemia will spread to the CNS in adults who do not receive CNS-directed therapy?
A. 05%
B. 10%
C. 20%
D. 35%

Correct answer is D. RATIONALE: It is important for radiation oncologists to understand the risk of CNS spread for patients with acute lymphoblastic leukemia and the need for CNS directed therapy. Incidence of CNS spread can exceed 35% in adult patients who did not receive CNS prophylaxis. Reference: DeVita.

293. In preparation for a bone marrow transplant, total body irradiation is delivered at a low dose rate to:
A. take advantage of cell cycle redistribution effects in any tumor cells that may be
harbored among the bone marrow cells.
B. provide time during the course of irradiation for reoxygenation of hypoxic bone
marrow stem cells to occur.
C. reduce the likelihood of the patient experiencing undesirable late complications
(eg, lung fibrosis).
D. differentially spare the platelet precursors, while maximizing killing of lymphoid
precursors.

Correct answer is C. RATIONALE: Although the bone marrow may not be spared by the use of low-dose-rate total body irradiation (due to the absence of sublethal damage recovery), the patient's other normal tissues would be spared, and accordingly, a lower frequency of early and late radiation effects would be expected.

320. Which of the following is the most appropriate staging workup for a plasma cell
neoplasm?
A. CT of the chest/abdomen/pelvis, bone marrow aspirate and biopsy, skeletal survey
B. CT of the chest/abdomen/pelvis, serum and urine protein electrophoresis, bone
marrow aspirate and biopsy
C. Bone marrow aspirate and biopsy, skeletal survey, serum and urine protein
electrophoresis
D. Serum and urine protein electrophoresis, PET scan, 24-hour urine protein, bone
marrow aspirate and biopsy

Correct answer is C. RATIONALE: It is important for radiation oncologists to be familiar with workup for plasma cell neoplasms to be able to recognize the difference between solitary plasmacytoma and multiple myeloma, since they are treated with a different regimen. Bone marrow aspirate and biopsy, skeletal survey, serum and urine protein electrophoresis are the three major tests for workup.

357. Which of the following genetic changes is the primary cause of chronic myelogenous leukemia (CML)?
A. Gene amplification
B. Retroviral insertion
C. Deletion of the CML gene
D. Chromosomal translocation

Correct answer is D. RATIONALE: Over 90% of chronic myelogenous leukemia (CML) cases result from a translocation between chromosomes 9 and 22 in which the bcr gene is placed adjacent to the abl gene, resulting in an aberrantly expressed gene product.

23. Which of the following treatments should be used as first-line therapy for gastric MALT lymphoma to achieve complete tumor remission in the majority of patients?
A. Focal radiation field therapy after initial biopsy
B. Combined chemotherapy and radiation therapy
C. Antibiotic therapy for Helicobacter pylori
D. Surgical resection combined with chemotherapy

Correct answer is C. RATIONALE: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is associated with Helicobacter pylori. More than two thirds of patients with this disease respond to antibiotic therapy, which is considered to be first-line therapy.

32. Which of the following Ann Arbor stages would be most appropriate for a 15-year-old boy who has Hodgkin lymphoma with clinical and radiographic evidence of left neck and left supraclavicular fossa lymphadenopathy, generalized pruritus, and a 7-lb weight loss over the past 6 months?
A. Stage IA
B. Stage IB
C. Stage IIA
D. Stage IIB

Correct answer is A. RATIONALE: The neck and supraclavicular fossa constitute one region for lymphoma staging; therefore, this patient would have stage I disease. B symptoms include the following: 1) Loss of >10% weight loss over 6 months, 2) fever, 3) night sweats. Pruritus is not considered a B symptom.

291. High dose systemic methotrexate is an appropriate therapy for which tumor?
(A) Ocular melanoma
(B) MALT orbital lymphoma
(C) Breast cancer metastatic to retina
(D) Ocular lymphoma without CNS involvement

Key: D
Rationale: Ocular lymphoma arises in the retina often co-exists with primary CNS lymphoma. Similar to primary CNS lymphoma this tumor is primarily managed with systemic therapy based upon high dose methotrexate with or without radiation therapy.
References: NCCN guidelines for CNS Tumors version 1.2012.

37. Which of the following imaging studies is most useful in the local evaluation of solitary plasmacytoma of the bone?
A. MRI
B. CT scan
C. Bone scan
D. PET scan

Correct answer is A. RATIONALE: It is important to evaluate the extent of the lesion appropriately. MRI provides the most complete anatomic information.

42. What is the most common subtype of classical Hodgkin lymphoma?
A. Large B-cell
B. Mixed cellularity
C. Nodular sclerosing
D. Lymphocyte depleted

Correct answer is C. RATIONALE: Nodular-sclerosing Hodgkin lymphoma is the most common subtype of classic Hodgkin lymphoma, accounting for more than two thirds of all cases. Mixed-cellularity Hodgkin lymphoma is the next most common subtype at 30%, followed by lymphocyte-rich and lymphocyte-depleted Hodgkin lymphoma.

54. What percent of children with acute lymphoblastic leukemia have CNS involvement at diagnosis?
A. 01% to 2%
B. 03% to 5%
C. 07% to 10%
D. 12% to 15%

Correct answer: ABCD. RATIONALE: CNS leukemia is present at diagnosis in 3% to 5% of children with acute lymphoblastic leukemia (ALL). REFERENCE: Pediatric Radiation Oncology. 3rd edition. Lippincott, Williams & Wilkins.

60. Which of the following chromosomal translocations is most commonly associated with chronic myelogenous leukemia (CML)?
A. t(8;21)
B. t(9;22)
C. t(12;15)
D. t(15;17)

Correct answer is B. RATIONALE: It is important to recognize the proper diagnosis of chronic myelogenous leukemia (CML). The relationship of CML to chromosomal translocation t(9;22) is well documented.

68. Which of the following characteristics is associated with the majority of patients who have follicular lymphoma?
A. It predominantly affects young adults.
B. The Bcl-2 gene rearrangement is typically present.
C. Bone marrow involvement is uncommon.
D. Without therapy, the median survival of patients is less than 5 years.

Correct answer is B. RATIONALE: The majority of patients with follicular lymphoma present with widespread disease and bone marrow involvement. The disease most commonly affects elderly patients. Due to its very indolent nature, even with observation, the median survival of these patients exceeds 5 years. The t(14;18) and Bcl-2 gene rearrangement is present in the majority of patients with follicular lymphoma.

72. Which of the following sets of unfavorable prognostic criteria is used by the EORTC for patients with early-stage Hodgkin lymphoma?
A. "B" symptoms, age, pathology, extranodal sites, and number of involved sites
B. "B" symptoms, age, erythrocyte sedimentation rate (ESR), mediastinal bulk, and number of involved sites
C. "B" symptoms, pathology, ESR, mediastinal bulk, and number of lymph node sites
D. Gender, ESR, mediastinal bulk, number of sites, and extranodal sites

Correct answer is B. RATIONALE: The EORTC used the following criteria for assigning patients with early-stage Hodgkin lymphoma to the favorable vs. unfavorable prognostic group: "B" symptoms, age, erythrocyte sedimentation rate (ESR), mediastinal bulk, and the number of nodal sites.

80. A patient with Hodgkin lymphoma has a 12-cm anterior mediastinal mass with bilateral involvement of the hilar lymph nodes and invasion of the anterior chest wall detected on CT scan. No disease is found below the diaphragm, and the patient has no "B" symptoms. Which of the following stages is associated with this patient's disease?
A. IAEX
B. IIAEX
C. IIIAEX
D. IVAEX

Correct answer is B. RATIONALE: Involvement of two lymph node regions (both hilum) on the same side of the diaphragm with localized contiguous involvement of a single extranodal site (chest wall), with >10-cm mass, and absence of "B" symptoms constitute stage IIAEX disease.

90. What is the probability that solitary plasmacytoma of the bone will progress to multiple myeloma within 10 years?
A. 10% to 20%
B. 30% to 40%
C. 60% to 70%
D. 80% to 90%

Correct answer is C. RATIONALE: It is important to know this fact for counseling patients. The majority of patients will progress to multiple myeloma, and surveillance/follow-up is important after primary therapy.

99. Which of the following chromosomal translocations is most closely associated with Burkitt's lymphoma?
A. t(8;14)
B. t(11;14)
C. t(11;18)
D. t(14;18)

Correct answer is A. RATIONALE: The (8;14) chromosomal translocation is most closely associated with Burkitt's lymphoma. The rest of the translocations are for mantle cell lymphoma (11;14), marginal cell lymphoma (11;18), and follicular cell (14;18) lymphoma.

106. Extramedullary plasmacytoma is most commonly located in the:
A. lower extremities.
B. head and neck.
C. lungs.
D. spine.

Correct answer is B. RATIONALE: It is important to know where extramedullary plasmacytoma is located in making a differential diagnosis. Extramedullary plasmacytoma may involve the nasal cavity, sinuses, nasopharynx, tonsils, and larynx.

186. Which of the following forms of leukemia is most appropriately treated with imatinib (STI571)?
A. Acute lymphocytic
B. Acute myelogenous
C. Chronic lymphocytic
D. Chronic myelogenous

Correct answer is D. RATIONALE: Imatinib is a tyrosine kinase inhibitor that is indicated for GI stromal tumors (GIST) and chronic myelogenous leukemia (CML). REFERENCE: FDA package insert.

191. Which of the following types of leukemia has the highest incidence?
A. Acute myelogenous
B. Acute lymphocytic
C. Chronic myelogenous
D. Chronic lymphocytic

Correct answer is D. RATIONALE: It's important to know which type of leukemia presents most frequently. Chronic lymphocytic leukemia (CLL) is most common.

205. Which of the following environmental exposures is a risk factor for the development of leukemia?
A. Chlorine
B. Benzene
C. Bromine
D. Radon

Correct answer is B. RATIONALE: It is important to be aware of risk factors for screening/counseling family members.

219. Which of the following radiation doses is most appropriate for treatment of a solitary plasmacytoma involving the femur?
A. 25 Gy
B. 36 Gy
C. 45 Gy
D. 60 Gy

Correct answer is C. RATIONALE: It is important to know that the radiation dose for solitary plasmacytoma of the femur is higher than that for myeloma. The content of this item is somewhat controversial, since some may chose to use 36 Gy for treatment based on a more recent analysis. However, the weight of the evidence supports the dose chosen (i.e., >40 Gy).

241. Which of the following factors is associated with the international prognostic score (IPS) for Hodgkin lymphoma?
A. Extranodal site
B. Performance status
C. Erythrocyte sedimentation rate
D. Serum albumin level

Correct answer is D. RATIONALE: A serum albumin level of <4 g/dL is the only factor belonging to the international prognostic score for Hodgkin lymphoma. REFERENCE: HasenClever, et al. New England Journal of Medicine (NEJM). 1998;1506-14.

251. Which of the following types of non-Hodgkin lymphoma is most aggressive?
A. Mycosis fungoides
B. Mantle cell
C. Extranodal marginal zone B-cell
D. Grades I and II follicular

Correct answer is B. RATIONALE: Mantle cell lymphoma is mostly diagnosed as stage IV disease and is known to have a moderately aggressive course with median survival around 3 years. Follicular, extranodal marginal zone, and mycosis fungoides all have an indolent disease course. REFERENCE: DeVita.

260. Which of the following histologies is most commonly associated with primary CNS lymphoma?
A. Mantle cell
B. Large B-cell
C. Anaplastic
D. Follicular

Correct answer is B. RATIONALE: Large B-cell lymphoma is the most common histology for CNS lymphoma. REFERENCE: DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles & Practice of Oncology. 6th edition. Lippincott, Philadelphia; 2001;2300.

280. Which of the following types of biopsy is most commonly used to diagnose Hodgkin lymphoma?
A. Excisional
B. Incisional
C. Fine-needle aspirate
D. Random

Correct answer is A. RATIONALE: Excisional biopsy is the preferred method of biopsy since it maintains architecture and sufficient material for immunohistochemistry flow cytometry.

291. A 32-year-old woman has clinical stage IIA Hodgkin lymphoma. Which of the following doses of radiation therapy would be most appropriate if the patient achieves a complete response after 6 cycles of ABVD chemotherapy?
A. 44 Gy
B. 36 Gy
C. 30.6 Gy
D. 20 Gy

Correct answer is C. RATIONALE: National Comprehensive Cancer Network guidelines specify a radiation dose of 30 Gy for treatment of non-bulky clinical stage IIA Hodgkin lymphoma.

300. Which of the following pathological features is characteristic of nodular lymphocyte-predominant Hodgkin lymphoma?
A. CD15−, CD30+, CD20+
B. CD15+, CD20+, CD22+
C. CD15+, CD30+, CD20−
D. CD20+, CD15−, CD30−

Correct answer is D. RATIONALE: Nodular lymphocyte-predominant Hodgkin lymphoma has distinct pathological features characterized by the presence of CD20+, CD15-, and CD30- cells. These features are different from classic Hodgkin lymphoma, which does not express CD20.

313. Which of the following treatments achieves the best disease control in patients with primary CNS lymphoma?
A. Corticosteroids
B. Whole-brain radiation therapy
C. Debulking of the tumor mass before administration of chemoradiation
D. Postsurgical chemotherapy only

Correct answer is B. RATIONALE: It is important to avoid use of corticosteroids prior to establishing a histological diagnosis since they can cause a change in tumor appearance. Surgical resection will not affect disease outcome because of its multifocal nature. For the same reason, whole-brain irradiation is warranted for achieving disease control. Compared to all the modalities, radiation therapy is associated with the worse neurotoxicity, particularly in elderly patients.

320. Which of the following factors has been found to affect the outcome of salvage therapy in patients with relapsed Hodgkin lymphoma?
A. Performance status
B. Extranodal site of relapse
C. Lactate dehydrogenase (LDH) levels
D. Erythrocyte sedimentation rate (ESR)

Correct answer is A. RATIONALE: The following factors are found to affect the outcome of patients with relapsed disease: duration of remission after initial therapy for <1 year, presence or absence of "B" symptoms, Karnofsky performance status <90, age >40 years.

343. Which of the following outcomes was demonstrated in the ECOG E1482 (Horning) trial, which randomized involved-field radiation therapy (IFRT) versus observation after 8 cycles of CHOP in patients with high- and intermediate-risk stage I or stage II non-Hodgkin lymphoma?
A. Time to progression was the same in both study groups.
B. Overall survival improved in patients who received IFRT after having a complete response to chemotherapy.
C. Six-year disease-free survival and failure-free survival improved in patients who received IFRT after having a complete response to chemotherapy.
D. Failure-free survival improved in patients who received IFRT after having a partial response to chemotherapy.

Correct answer is C. RATIONALE: Patients with a complete response had improved 6-year disease-free survival (DFS), failure-free survival (FFS), and time to progression in the IFRT arm over the observation arm, but there was no difference in overall survival (OS). Patients achieving a complete response (CR) after 8 cycles of CHOP were treated to 30 Gy of IFRT, while patients with a partial response received 40 Gy of IFRT. Conversion to CR did not significantly influence clinical outcome of patients with initial PR from chemotherapy. REFERENCE: Horning, et al. Journal of Clinical Oncology (JCO). 2004;22(15).

358. Rituximab binds to which of the following CD receptors?
A. CD20
B. CD15
C. CD8
D. CD4


Correct answer is A. RATIONALE: Rituximab is a chimeric monoclonal antibody that binds to the CD20 receptor expressed on B-cells to induce apoptosis. REFERENCE: FDA package insert.


132. How would a stage IIB classical nodular sclerosing Hodgkin lymphoma in a 30-year-old female with a 14 cm mediastinal mass be characterized?
(A) Early stage favorable
(B) Early stage unfavorable
(C) Advanced stage favorable
(D) Advanced stage unfavorable


Key: B
Rationale: Stage I and II are early stage, while stage III and IV belong to advanced stage groups. Patients with bulky disease, especially when coupled with “B” symptoms are known to have less favorable outcome and stage IIB bulky patients do belong to” advanced early stage” group.