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130 Cards in this Set
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283. Which of the following salivary gland carcinomas has the worst prognosis? |
Correct answer is A. RATIONALE: Ductal carcinoma of the salivary gland is rare. It is characterized by its histologic resemblance to ductal carcinoma of the breast and prostate with a highly aggressive biological behavior. Polymorphous adenocarcinoma is least aggressive. |
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271. Comprehensive irradiation for a stage T0N2b squamous cell carcinoma in the level II lymph nodes of the neck will decrease the emergence of the primary site from: A. 70% to 30%. B. 50% to 25%. C. 30% to 15%. D. 10% to 2%. |
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259. Which of the following induction chemotherapy regimens would be most appropriate before administration of radiation therapy for a patient with stage T2N2 carcinoma of the pyriform sinus? A. Docetaxel, cisplatin, and 5-FU B. Docetaxel and cisplatin only C. Cisplatin and 5-FU only D. Cisplatin and cetuximab |
Correct answer is A. RATIONALE: The GORTEC trial of patients with larynx/hypopharynx cancer shows that induction TPF (docetaxel, cisplatin, and 5-FU) induction chemotherapy is superior to PF (cisplatin and 5-FU) induction chemotherapy for organ preservation. REFERENCE: Calais G, et al. GORTEC 2000-01 trial. ASCO. 2006. |
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54. Which is NOT a structure of the supraglottic larynx? (A) Infrahyoid epiglottis (B) Suprahyoid epiglottis (C) Pre-epiglottic space (D) False vocal cords |
Key: C |
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246. Radiation therapy for a patient with stage T1N0 carcinoma of the false vocal cord versus a stage T1N0 lesion of the true vocal cord should involve: A. unilateral treatment. B. a hypofractionated regimen. C. a shorter treatment time. D. treating the regional lymph nodes. |
Correct answer is D. RATIONALE: The risk for regional lymph node involvement is 20% to 30% for supraglottic cancer compared to <1% for a stage T1 lesion. REFERENCE: Lindberg, RD. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1972;29:1446. |
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169. Which of the following is CORRECT regarding a patient with a non-keratinizing undifferentiated nasopharyngeal carcinoma extending into the posterior nasal cavity along with bilateral level II lymphadenopathy (< 5cm)? (A) The stage is IVA. (B) The T classification is T1. (C) The N classification is N3. (D) The tumor histology is WHO Type I. |
Key: B Rationale: The correct T classification is T1, which includes tumors confined to the nasopharynx or tumors with extension into the oropharynx and/or nasal cavity without parapharyngeal extension. Note that in the most recent AJCC staging system (7th edition 2010), parapharyngeal extension alone distinguishes T1 from T2 primaries (1). Tumors with extension into the oropharynx and/or nasal cavity without parapharyngeal extension, previously classified as T2a, are now classified as T1 reflecting their more favorable prognosis and the negative prognostic impact of parapharyngeal extension. The distribution and prognostic impact of regional nodal involvement in nasopharyngeal cancer is different from other head and neck cancers, hence the unique N classification system. This patient has N2 disease due to bilateral cervical metastases, 6 cm or less in dimension, above the supraclavicular fossa. The correct Stage grouping is III, T1N2M0. There are three WHO histologic classifications: Type I – keratinizing squamous cell carcinoma, Type II non-keratinizing differentiated carcinoma, and Type III – non-keratinizing undifferentiated carcinoma. Type III is the most common type in both North American (about 63% of patients) and endemic Asian populations (about 95% of patients). There is a greater proportion of Type I disease in North America (about 25% of patients) compared to endemic areas (about 2% of patients) (2). References: Edge, S.B. and American Joint Committee on Cancer. AJCC cancer staging manual. 7th ed2010, New York: Springer. xiv, 648 p. Wei, W.I. and J.S. Sham, Nasopharyngeal carcinoma. Lancet, 2005. 365(9476): p. 2041-54. |
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170. The rate of laryngeal preservation at 2-years after non-surgical treatment in the Department of Veterans Affairs Laryngeal Cancer Study Group trial (NEJM 1991) was approximately: (A) 20%. (B) 40%. (C) 60%. (D) 80%. |
Key: C References: N Engl J Med. 1991 Jun 13; 324(24):1685-90. |
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181. The 5-year overall survival for patients with pyriform sinus cancer treated by either surgical or non-surgical treatment on EORTC phase 3 trial (24891) was approximately: (A) <10%. (B) 30%. (C) 50%. (D) 70%. |
Key: B References: Lefebvre JL, et al. J Natl Cancer Inst. 1996 Jul 3; 88(13):890-9. |
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157. What is the MOST appropriate management for a 52-year-old male with a T4N2M0 nasopharyngeal carcinoma? (A) Definitive radiation therapy alone (B) Induction chemotherapy followed by radiotherapy (C) Craniofacial resection followed by chemoradiation (D) Concurrent chemoradiation with adjuvant chemotherapy |
Key: D Rationale: The standard of care for this patient would be concurrent chemoradiation with Cisplatin-based chemotherapy with or without adjuvant chemotherapy. This was established by the landmark Intergroup Study 0099, which randomized patients with locally advanced disease to radiotherapy alone versus chemoradiation (1). The role of concurrent chemoradiation was also confirmed by a number of studies conducted in endemic populations of nasopharyngeal carcinoma (2,3). Intergroup 0099 demonstrated an improvement in survival with the addition of 3 cycles of Cisplatin 100 mg/m2 on days 1, 22, and 43 concurrent with radiation followed by adjuvant chemotherapy with CDDP/5-FU. Compliance with adjuvant chemotherapy was poor with only about 55% of patients able to complete all 3 cycles, so it is controversial whether adjuvant chemotherapy is necessary. A recently reported Chinese multicenter study randomized patients with locally advanced nasopharyngeal carcinoma to chemoradiation alone versus chemoradiation plus adjuvant chemotherapy. In early follow-up, 2-year failure-free survival is not significantly different between the arms. Longer follow up will be needed to confirm the lack of benefit for the addition of adjuvant chemotherapy. Even with locally advanced disease and T4 primary tumors, many patients fare well with concurrent chemoradiation. Modern chemoradiation series with IMRT demonstrate very high rates of locoregional control. Lee et al reviewed the UCSF experience and reported 4-year estimated OS of 88% and 4-year locoregional progression free rate of 98% (4). Meta-analyses of chemotherapy trials have demonstrated that the greatest improvement in survival is associated with concomitant chemotherapy with radiation, with no significant improvement associated with neoadjuvant or adjuvant chemotherapy (5,6). References: Al-Sarraf, M., et al., Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: phase III randomized Intergroup study 0099. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 1998. 16(4): p. 1310-7. Lin, J.C., et al., Phase III study of concurrent chemoradiotherapy versus radiotherapy alone for advanced nasopharyngeal carcinoma: positive effect on overall and progression-free survival. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 2003. 21(4): p. 631-7. Wee, J., et al., Randomized trial of radiotherapy versus concurrent chemoradiotherapy followed by adjuvant chemotherapy in patients with American Joint Committee on Cancer/International Union against cancer stage III and IV nasopharyngeal cancer of the endemic variety. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 2005. 23(27): p. 6730-8. Lee, N., et al., Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: an update of the UCSF experience. International journal of radiation oncology, biology, physics, 2002. 53(1): p. 12-22. Baujat, B., et al., Chemotherapy in locally advanced nasopharyngeal carcinoma: an individual patient data meta-analysis of eight randomized trials and 1753 patients. International journal of radiation oncology, biology, physics, 2006. 64(1): p. 47-56. Langendijk, J.A., et al., The additional value of chemotherapy to radiotherapy in locally advanced nasopharyngeal carcinoma: a meta-analysis of the published literature. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 2004. 22(22): p. 4604-12. |
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158. Which of the following statements is CORRECT regarding the treatment for a patient with a T2 verrucous carcinoma of the buccal mucosa? (A) A surgical resection is generally the preferred treatment. (B) Radiotherapy should be avoided because of the high risk of dedifferentiation. (C) The local failure rate with either surgery or radiotherapy is approximately 50%. (D) Higher dose radiation is required compared to more conventional squamous cell carcinoma. |
Key: A Rationale: With early stage tumors of the buccal mucosa, surgery is generally the preferred form of therapy. However, if the patient is medically inoperable or if the morbidity associated with a surgical resection is too great, then radiotherapy may be offered. Many recurrent tumors appear to be more biologically aggressive than the original tumor but this holds for all forms of treatment (1). There is little evidence that radiotherapy presents a higher degree of risk (2,3). The doses used are the same as for other forms of squamous cell carcinomas and the results of treatment are comparable with the expected local control rate being in the range of 70-75% (4,5). References: Koch BB, Trask DK, Hoffman, et al. National survey of head and neck verrucous carcinoma: Patterns of presentation, care, and outcome. Cancer 92: 110-120, 2001. Jyothirmni R, Sankananarayanan R, Varghese C, et al. Radiotherapy in the treatment of verrucous carcinoma of the oral cavity. Oral Oncol 33: 124-128, 1997. Nair MK, Sankaranarayanan R, Madhu CS. Oral verrucous carcinoma. Treatment with radiotherapy. Cancer 61: 458-461, 1988. Wang CC. Radiation Therapy for Head and Neck Neoplasms, 3rd Ed, John Wiley, 1996, Ch 6. Nair MK, Sankaranerayanan R, Padmanabhan Tk. Evaluation of the role of radiotherapy in the management of carcinoma of the buccal mucosa. Cancer 61: 1326-1331, 1988. |
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220. Which of the following radiation therapy regimens is best for a patient with stage T1 glottic larynx carcinoma? A. Keeping total treatment time to <6 weeks B. Hyperfractionation to allow dose escalation C. 1.8 Gy per fraction to minimize toxicity D. 63 Gy in 28 fractions of IMRT |
Correct answer is A. RATIONALE: The optimal treatment regimen is 63 Gy in 28 fractions, which yields the best balance of toxicity and efficacy. There is no advantage of hyperfractionated radiation therapy for stage T1 glottic lesions. At the present time, IMRT is not appropriate for a stage T1 glottic tumor. REFERENCE: Le QT, et al. Influence of fraction size, total dose, and overall time on local control of stage T1-T2 glottic carcinoma. International Journal of Radiation Oncology, Biology, Physics (Int J of Radiat Oncol Biol Phys). 1997;37:115-126. |
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206. What is the standard treatment for a supraglottic larynx carcinoma extending through the thyrohyoid membrane into the strap muscles? A. Total laryngectomy B. Radiation therapy alone C. Concurrent chemoradiation D. Induction chemotherapy, followed by radiation therapy |
Correct answer is A. RATIONALE: Standard treatment for a stage T4 lesion would require total laryngectomy. |
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192. Which of the following treatments is most appropriate for a patient with stage T2N0 glottic larynx carcinoma with impaired vocal cord mobility? A. Hyperfractionated radiation therapy to escalate radiation dose B. Conventionally fractionated radiation therapy of 2 Gy per day C. Cisplatin with delayed concomitant boost radiation therapy D. Induction chemotherapy, followed by radiation therapy for responders |
Correct answer is A. RATIONALE: The RTOG 95-12 trial demonstrated that hyperfractionated radiation improved local control compared to conventional treatment (per ASTRO 2006). |
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178. Which of the following histological subtypes of thyroid cancer has the worst prognosis? A. Hürthle cell B. Classic papillary C. Follicular variant of papillary D. Giant cell variant of anaplastic |
Correct answer is D. RATIONALE: The prognosis is similar for the follicular variant of papillary cancer, classic papillary cancer, and classic follicular cancer. |
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164. Which of the following patients with thyroid carcinoma is most likely to have the best prognosis, assuming that all other prognostic factors are equal? A. A 25-year-old patient with papillary carcinoma B. A 25-year-old patient with medullary carcinoma C. A 55-year-old patient with papillary carcinoma D. A 55-year-old patient with follicular carcinoma |
Correct answer is A. RATIONALE: Age is the most powerful prognostic factor in papillary and follicular thyroid carcinoma. In adults, younger is better. The breakpoint in the staging and classification systems is 45 years old, such that the answers in this question are not equivocal. |
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162. What is the most appropriate radiation dose for patients with Graves’ ophthalmopathy? A. 10 Gy in 5 fractions B. 20 Gy in 10 fractions C. 30 Gy in 15 fractions D. 40 Gy in 20 fractions |
Correct answer is B. REFERENCE: Marquez SD. Long-term results of irradiation for patients with progressive Graves' ophthalmopathy. International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 2001 Nov 1;51(3):766-74. |
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150. According to the RTOG 0129 trial, which of the following patients with squamous cell carcinoma of the tonsil has the worst overall survival rate? Smoking History HPV Status Disease Stage A. 10-pack-year Positive T3N1 B. 10-pack-year Negative T3N1 C. 30-pack-year Positive T1N2b D. 30-pack-year Negative T1N1 |
Correct answer is D. RATIONALE: It is important for candidates to understand recursive-partitioning analysis to identify prognostic factors for oropharyngeal cancer. Option A represents a low-risk group (5-year survival rate = 93%); options B and C represent intermediate-risk groups (5-year survival rate = 70.8%); option D represents a high-risk group (5-year survival rate = 46.2%). REFERENCE: New England Journal of Medicine. 2010;363:24-35. |
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269. For which of the following parotid tumors can the post-operative radiotherapy be withheld based on the histologic subtype alone? (A) Adenocarcinoma (B) Acinic cell carcinoma (C) Adenoid cystic carcinoma (D) Squamous cell carcinoma |
Key: B References: North Int J Radiat Oncol Biol Phys 1990 Jun; 18(6):1319-26. |
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148. Which of the following treatment results is most likely to be associated with patients who have ocular melanoma? A. Brachytherapy and enucleation result in similar overall survival rates for medium-sized tumors. B. Enucleation results in a higher overall survival rate than brachytherapy for medium-sized tumors. C. Brachytherapy results in a lower local recurrence rate than charged particle irradiation for large-sized tumors. D. EBRT followed by enucleation results in a higher overall survival rate than enucleation alone for large choroidal tumors. |
Correct answer is A. RATIONALE: COMS report 18: Medium tumors: Both brachytherapy and enucleation yield 5-year overall survival rates of 82%. Per COMS report 10: Large tumors: EBRT adds no survival benefit to enucleation. Several studies have suggested lower rates of recurrence with charged particle irradiation. |
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136. A 60-year-old patient with a long history of tobacco use presents with an enlarging mass in the neck. Which of the following diagnostic tests is most appropriate? A. PET scan B. Incisional biopsy C. Excisional biopsy D. Fine-needle aspiration |
Correct answer is D. RATIONALE: An incisional/excisional biopsy for a patient with a presumed squamous cell carcinoma is inappropriate because it may cause violation of the neck, which may require postoperative radiation. Fine-needle aspiration (FNA) is the first treatment choice unless a lymphoma is suspected. |
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195. Which of the following is appropriate coverage for subclinical disease in a patient undergoing radiotherapy for nasopharyngeal carcinoma? (A) The posterior cervical nodes should not be covered. (B) The bilateral retropharyngeal nodes should be covered. (C) The cavernous sinus should be covered with disease involving the maxillary sinus. (D) The posterior one-third to one-half of the nasal cavity should be covered only in patients with nasal obstruction. |
Key: B Rationale: Nasopharyngeal carcinoma is associated with a high risk of retropharyngeal nodal involvement, which should be electively covered in all patients (1). Posterior cervical chain involvement is also commonly seen and must be included in the neck target volumes. The cavernous sinus is at risk in patients with higher T-stage primaries (T3 to T4 tumors). Elective coverage of the cavernous sinus should be considered with tumor extent involving these anatomic sites: foramen ovale, foramen lacerum, foramen rotundum, sphenoid sinus, and clivus (2). In particular, foramen ovale is the most common pathway of spread to the skull base in patients with cavernous sinus invasion. The posterior one-third to one-half of the nasal cavity and maxillary sinuses should be electively covered in all patients (3). References: Wang, X.S., et al., Patterns of retropharyngeal node metastasis in nasopharyngeal carcinoma. International journal of radiation oncology, biology, physics, 2009. 73(1): p. 194-201. Liang, S.B., et al., Extension of local disease in nasopharyngeal carcinoma detected by magnetic resonance imaging: improvement of clinical target volume delineation. International journal of radiation oncology, biology, physics, 2009. 75(3): p. 742-50. Ang, K.K. and A.S. Garden, Radiotherapy for head and neck cancers: indications and techniques. 3rd ed2006, Philadelphia, PA: Lippincott Williams & Wilkins, xi, p. 212. |
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122. An otherwise healthy 60-year-old patient has a 5 cm squamous cell carcinoma of the base of tongue with bilateral jugulodigastric lymph node involvement. Which of the following systemic therapy regimens combined with radiation therapy is most appropriate for this patient? A. Cisplatin at 30 mg/m2 weekly B. Cetuximab at 250 mg/m2 weekly C. Cisplatin at 100 mg/m2 every 3 weeks D. Carboplatin at 100 mg/m2 and paclitaxel at 20 mg/m2 every 3 weeks |
Correct answer is C. RATIONALE: Although carboplatin/Taxol is a commonly used chemocombination, it has not been proven in a prospective trial to be better than radiation therapy alone or standard cisplatin therapy. Cetuximab can be used in lieu of cisplatin for elderly patients or patients with a poor performance status; a loading dose is needed before radiation. |
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94. A 58-year-old man with a 100-pack-year smoking history presents with a 4 cm, right jugulodigastric lymph node. Biopsy of the lymph node reveals squamous cell carcinoma. What is the most likely primary tumor site? A. Nasal vestibule B. Base of tongue C. Pyriform sinus D. Glottic larynx |
Correct answer is B. RATIONALE: It is important to understand that the most common primary cancer site for a patient with a squamous cell carcinoma of unknown primary is the oropharynx. |
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88. Which of the following sites of involvement by maxillary sinus carcinoma is associated with the worst prognosis? A. Hard palate B. Pterygoid fossa C. Cribriform plate D. Orbital apex |
Correct answer is D. RATIONALE: Please refer to the current AJCC staging. The location and the extent of the mucosal lesion within the maxillary sinus have prognostic significance. Lesions involving the posterosuperior portion have a poor prognosis. It is important to know the stage of maxillary sinus cancer to determine the difference between resectable and unresectable disease. Orbital apex involvement represents a T4b disease and is considered to be an unresectable, very advanced local disease. |
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78. According to prospective randomized studies for head and neck cancer, which of the following is an absolute indication for postoperative chemotherapy and radiation? A. >4 positive lymph nodes B. 3 cm positive lymph nodes C. Presence of a positive margin D. Presence of perineural invasion |
Correct answer is C. RATIONALE: The indications for the addition of postoperative chemoradiation therapy are positive margins and extranodal extension. The other options are not based on the combined EORTC & RTOG analyses. |
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62. Which of the following tumor sites has the highest risk for metastasis to the Rouvière's lymph nodes? A. Tonsil B. Oral cavity C. Pyriform sinus D. Nasopharynx |
Correct answer is D. RATIONALE: The nasopharynx/hypopharynx tumor sites (specifically the posterior pharyngeal wall) are the most likely primary cancer sites to spread to the Rouvière's lymph nodes. |
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59. According to the Collaborative ocular melanoma study (COMS) protocol guidelines, the dose prescription point for the radiation treatment of an ocular melanoma is: A. fixed at a depth of 5 mm. B. at the tumor apex. C. at the tumor apex if the tumor height is 5 mm, and at a depth of 5 mm if the tumor height is 5 mm. D. at the tumor apex if the tumor height is 5 mm, and at a depth of 5 mm if the tumor height is 5 mm. |
Correct answer is D. RATIONALE: According to the collaborative ocular melanoma study (COMS) protocol, the prescription point is at the tumor apex for tumors that are 5 mm or greater in height, and at 5 mm for tumors that are less than 5 mm in height. The American Brachytherapy Society (ABS), on the other hand, recommends a prescription point at the tumor apex. REFERENCE: http://www.jhu.edu/wctb/coms/index.htm (General information: Radiation Therapy). Nag S, et al. International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 2003;56(2):544-555. |
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46. Which of the following management strategies is most appropriate for a 34-year-old woman with a 3 cm lymphepithelioma limited to the nasopharynx and no evidence of lymph node involvement? A. Radiation therapy to a total dose of 70 Gy alone B. Carboplatin and paclitaxel weekly with concurrent radiation therapy to a total dose of 70 Gy C. Cisplatin at 30 mg/m2 weekly with hyperfractionated radiation therapy to a total dose of 76.4 Gy D. Cisplatin at 100 mg/m2 every 3 weeks with concurrent radiation therapy to a total dose of 70 Gy, followed by 3 cycles of adjuvant cisplatin and 5-FU |
Correct answer is A. RATIONALE: Knowing that radiation therapy alone is a very effective treatment for early-stage nasopharyngeal cancer is vital. Chemotherapy has been proven to be effective for stage III and IV disease only. |
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16. A 68-year-old smoker has a 2 cm squamous cell carcinoma of the tonsil with no clinical evidence of lymph node involvement. Which of the following treatments would be most appropriate? A. Concurrent chemotherapy and radiation therapy B. Induction chemotherapy, followed by concurrent chemoradiation therapy C. Radiation therapy to the oropharynx and ipsilateral cervical lymph nodes D. A radical tonsillectomy and bilateral lymph node dissection |
Correct answer is C. RATIONALE: It is important to understand that chemotherapy has not improved outcomes for patients with early-stage oropharyngeal cancer. In fact, RTOG 0022 has a 94% locoregional control rate with radiation therapy alone for this cohort of patients. REFERENCE: International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 2010;76(5):1333-8. |
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190. What is the MOST appropriate treatment for a patient with a p16 (-) T4N2M0 squamous cell carcinoma of the base of tongue? (A) Conventionally fractionated radiotherapy (B) Concurrent chemotherapy and radiotherapy (C) Transoral laser microsurgery followed by radiotherapy (D) Induction chemotherapy followed by transoral laser microsurgery |
Key: B Rationale: This patient has a locally advanced oropharyngeal squamous carcinoma. The standard of care is concurrent chemotherapy and radiotherapy, which is superior to radiotherapy alone (1). Surgery is generally reserved for salvage of treatment failures. Transoral laser microsurgery is contraindicated in tongue base tumors that extend ventrally into the floor of mouth (2). There is no data to support induction chemotherapy followed by surgery in this situation. References: Denis F, Garaud P, Bardet E, et al. Final Results of the 94-01 French Head and Neck Oncology and Radiotherapy Group Randomized Trial Comparing Radiotherapy Alone With Concomitant Radiochemotherapy in Advanced-Stage Oropharynx Carcinoma. J Clin Oncol 22:69-76. 2004. Haughey BH, Hinni ML, Salassa JR, et al.Transoral Laser Microsurgery as Primary Treatment for Advanced-stage Oropharyngeal cancer: A United States multicenter study. Head & Neck—DOI 10.1002/hed December 2011. |
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145. Which of the following is TRUE regarding the use of radiotherapy for a squamous cell carcinoma of the upper lip? (A) Involvement of the commissure is a relative contraindication. (B) The submental nodes would not be at risk. (C) Brachytherapy is typically combined with external beam for early lesions. (D) A lead shield should be placed behind the lip when electron beam is used. |
Key: D Rationale: Lymphatic vessels from both the upper and lower lip primarily drain to the submandibular and submental nodes which in turn drain to the deep cervical chain (1). On occasion, the upper lip may also drain to the preauricular and infraparotid nodes. While the majority of early lesions of the lip can be treated with a simple, surgical excision, it is generally thought that involvement of the commissure yield poorer cosmesis with surgery should be treated with radiotherapy (2,3). Brachytherapy alone yields excellent local control results in the range of 85-90% for T1 and T2 lesions (4,5). For T3 and T4 lesions, it is necessary to treat the draining lymph nodes (6,7). This can be done with lateral fields encompassing the primary and nodes with the primary lesion being boosted either with brachytherapy or with an enface electron or othovoltage beam with appropriate shielding. References: Renner GJ, Zitsch RP. Cancer of the lip. In: Cancer of the Head and Neck, 3rd Ed., Eds. Myers EN, Suen JY. WB Saunders, Philadelphia, 1996, pp.294-320. Harrison LB: Applications of brachytherapy in head and neck cancer. Semin Surg Oncol 13: 177-184, 1997. Sranc MF, Fogel M, Dische S. Comparison of lip function: Surgery vs. radiotherapy. Br J Plat Surg 40: 598-604, 1987. Oreccia R, Rampino M, Gribudo S, et al. Interstitial brachytherapy for carcinomas of the lower lip. Results of treatment. Tumori 77: 336-338, 1991. |
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166. The radiotherapeutic treatment of head and neck cancer of unknown origin should: (A) include the entire pharyngeal axis in all cases. (B) exclude the nasopharynx in non-Asian patients. (C) always involve concurrent chemotherapy. (D) use a dose of >50 Gy to mucosal sites at risk. |
Key: D |
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210. A tumor in which of the following salivary glands is MOST LIKELY to be malignant? (A) Minor (B) Parotid (C) Sublingual (D) Submandibular |
Key: C References: Devita text book. |
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5. Which type of salivary gland tumor is most likely to be benign? A. Minor salivary B. Submandibular C. Sublingual D. Parotid |
Correct answer is D. RATIONALE: There is an inverse relationship between the size of the salivary gland and the likelihood of malignancy. |
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328. Which of the following foramina at the skull base should be included in the postoperative radiation field for a patient with adenoid cystic carcinoma of the submandibular gland? A. Ovale B. Jugular C. Rotundum D. Lacerum |
Correct answer is A. RATIONALE: Following the pathway of the V3 to the skull base leads to the foramina ovale. |
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302. For a patient with T3N2bM0 squamous carcinoma of the base of tongue, IMRT compared to 3D-CRT is: (A) more effective in reducing xerostomia. (B) associated with less mucositis. (C) contraindicated due to a high risk of marginal miss. (D) not indicated since only ipsilateral nodes need to be treated. |
Key: A Rationale: Parotid glands are typically irradiated during treatment of oropharyngeal cancers, unless special technical precautions are taken (1, 2). A multi-center randomized study showed that IMRT is superior to conventional radiotherapy techniques in sparing parotid gland function and reducing xerostomia (3). A risk of missing the tumor increases with any conformal treatment technique, including IMRT. However, data from multiple institutions shows excellent cure rates with IMRT in the treatment of node positive References: Lee N, Puri DR, Blanco AI, et al. IMRT in Head and Neck cancers: an update. Head & Neck —DOI 10.1002/ hed April 2007. Eisbruch A, Ten Haken RK, Kim HM, et al. Dose, volume, and function relationships in parotid salivary glands following conformal and intensity-modulated irradiation of head and neck cancer. Int J Radiat Oncol Biol Phys 1999; 45:577-587, 3. Nutting CM, Morden JP, Harrington KJ, et al. Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomized controlled trial. Lancet Oncol 2011; 12: 127–36. |
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223. What was the concurrent chemotherapy regimen used in RTOG 91-11 for laryngeal preservation? (A) Cisplatin, weekly for 6 cycles (B) Cisplatin, every three weeks for 3 cycles (C) Cisplatin and 5-FU, for 3 cycles (D) Carboplatinum and paclitaxel, weekly for 6 cycles |
Key: B References: Forastiere AA et al. N Engl J Med. 2003 Nov 27; 349(22):2091-8. |
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321. What is the best treatment approach for patients with anaplastic thyroid carcinoma? A. Maximal resection, followed by combined doxorubicin and hyperfractionated radiation therapy B. Induction chemotherapy with doxorubicin, followed by EBRT C. Total thyroidectomy, followed by radioactive iodine and EBRT D. Thyroid ablation with radioactive iodine, followed by definitive resection |
Correct answer is A. RATIONALE: Based on a single institutional study, treatment of anaplastic giant and spindle cell carcinoma of the thyroid gland involves combined doxorubicin (Adriamycin) and hyperfractionated radiation therapy. REFERENCE: Kim JH, Leeper RD. A new approach. Cancer. September 15, 1983;52(6):954-7. |
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294. Which of the following maxillary sinus carcinomas is most likely to benefit from elective lymph node irradiation? A. Stage T2 undifferentiated carcinoma involving the maxillary tuberosity B. Stage T2 squamous cell carcinoma originating above Ohngren's line C. Stage T3 adenoid cystic carcinoma with perineural invasion D. Stage T4 squamous cell carcinoma invading the orbit |
Correct answer is D. REFERENCES: Based on studies from Le. International Journal of Radiation Oncology, Biology, Physics (IJROBP). 2000;46(3):541-549. Jiang SB. Radiotherapy Oncology. 1991;21(3):193-200. |
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286. Which of the following carcinomas of the parotid gland has the highest risk for regional spread? A. Ductal B. High-grade mucoepidermoid C. Adenoid cystic D. Adenocarcinoma |
Correct answer is ABCD. REFERENCE: Izandro Re´gis de Brito Santos, MD, Luiz P. Kowalski, MD. Multivariate analysis of risk factors for neck metastases in surgically treated parotid carcinomas. Archives of Otolaryngology-Head & Neck Surgery (Arch Otolaryngol Head Neck Surg). 2001;127:56-60. |
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280. What is the expected 5-year local control rate for a patient with stage T1-T2N0 tonsillar carcinoma treated with definitive radiation therapy? A. 80% B. 60% C. 40% D. 20% |
Correct answer is A. REFERENCE: Journal of Clinical Oncology. Jun 2000;18(11):2219-25. |
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265. What is the contralateral neck failure rate in patients with stage T1-T2N0 tonsillar carcinoma treated with ipsilateral neck irradiation alone? A. 15% B. 10% C. 5% D. <1% |
Correct answer is C and D. RATIONALE: O'Sullivan, et al, reported a 3-year local regional control (LRC) of 77% and a contralateral neck failure rate of only 3.5% in 228 patients who have tonsillar carcinoma treated with ipsilateral neck radiation therapy (RT) alone. Specifically, there was no contralateral neck failure in 118 patients with stage T1-T2N0 tumor in that series (O'Sullivan, et al, 2001). |
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252. Which of the following statements about oropharyngeal squamous cell carcinoma is true? A. The soft palate is the most common site. B. The incidence continues to increase in the United States. C. HPV infection is least likely to be associated with the condition. D. HPV-positive tumors are more likely to be well differentiated. |
Correct answer is B. RATIONALE: The tonsil is the most common site of oropharyngeal squamous cell carcinoma, followed by the base of tongue. The incidence of oropharyngeal squamous cell carcinoma in the tonsil and base of tongue continued to increase by 3.9% and 2.1% per year through the late 1990s in the United States. HPV-positive tumors are more likely to be undifferentiated, have basaloid features, and are more frequently associated with lymph node metastasis. |
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237. Intergroup Study 0099 for nasopharyngeal cancer (NPC) concluded that: A. adjuvant 5-FU and cisplatin chemotherapy were well tolerated with high treatment completion rates. B. the results of the radiation therapy alone arm were worse than expected compared to other published results. C. chemotherapy improved 3-year event-free survival only. D. chemotherapy improved 3-year overall survival only. |
Correct answer is B. RATIONALE: When compared with radiation therapy (RT) alone, chemotherapy resulted in a significant benefit for both event-free survival (EFS) and overall survival (OS) at 3 years and 5 years. However, controversies remain, particularly regarding the magnitude of benefit because the results of the RT alone arm were grossly inferior to those achieved by most centers. Adjuvant chemotherapy was poorly tolerated. |
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223. A patient who receives radiation therapy to the primary site only for clinical stage N0 oral cavity cancer is most likely to have a neck failure rate of: A. 70%. B. 50%. C. 30%. D. 10%. |
Correct answer is C. RATIONALE: Turner, et al, (1996) analyzed a series of 268 patients who received radiation therapy to the primary site only for oral cavity cancer with clinically negative lymph nodes (stage N0) and found an overall neck failure rate of 31%. The risk of subsequent neck failure varied between the sites of oral cavity and was as high as 40% for oral tongue cancers. |
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261. For a healthy 45-year-old non-smoker with a cT1N1M0 squamous cell carcinoma of the right palatine tonsil with a level 2A node, what is the MOST appropriate treatment? (A) Induction chemotherapy followed by concurrent chemoradiotherapy (B) Radiotherapy to the right tonsil and bilateral cervical lymph nodes (C) Radiotherapy to the right tonsil and ipsilateral cervical lymph nodes (D) Tonsillectomy and neck dissection followed by postoperative radiation |
Key: C Rationale: This patient has an excellent prognosis. With radiotherapy alone, the 5-year rate of locoregional control for T1N1 oropharyngeal squamous cancers is 95% (1). The 5-year rate of distant metastases for patients with N1/2a disease treated without systemic therapy is 11% (1). The risk of occult contralateral nodal metastases is < 5% in cases of well lateralized tonsillar cancers. With ipsilateral techniques, only 2-3% of patients develop contralateral neck failures (2,3). The morbidity of treating bilateral cervical nodal regions or the addition of chemotherapy is not justifiable in these cases. Chemotherapy by itself is not a curative treatment for head and neck squamous cell carcinomas. References: Garden AS, Asper JA, Morrison WH, et al. Is concurrent chemoradiation the treatment of choice for all patients with Stage III or IV head and neck carcinoma? Cancer 2004; 100:1171e1178. Chronowski GM, Garden AS, Morrison WH, et al. Unilateral Radiotherapy for the Treatment of Tonsil Cancer. Int J Radiation Oncol Biol Phys, Vol. 83, No. 1, pp. 204e209, 2012. O’Sullivan B, Warde P, Grice B, et al. The benefits and pitfalls of ipsilateral radiotherapy in carcinoma of the tonsillar region. Int J Radiat Oncol Biol Phys 2001; 51:332e343. |
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208. What is the expected 5-year survival rate for a patient who has oral cavity cancer with distant metastasis? A. 50% B. 30% C. 10% D. 5% |
Correct answer is B. RATIONALE: According to SEER data, regional lymph node metastasis decreases the 5-year survival rate by 40%. Distant metastasis further reduces the survival rate to about 30%, ranging from 27% for oral tongue to 37% for lip cancer. |
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193. Which of the following oral cavity cancers has the worst prognosis? A. Oral tongue B. Floor of mouth C. Alveolar ridge D. Buccal gingiva |
Correct answer is A. RATIONALE: According to SEER data, a lip primary has the best prognosis with a 10-year survival rate of 87%, followed by the gums (70%) and the floor of mouth (48%). The alveolar ridge and buccal gingiva are both portions of the gums. Oral tongue cancer has the worst 10-year survival rate of 45%. |
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178. Oral cavity cancer most commonly occurs in which of the following sites in both American men and women? A. Lip B. Oral tongue C. Floor of mouth D. Buccal mucosa |
Correct answer is B. RATIONALE: According to SEER 2007 data: Option B, the oral tongue, is the most common site for cancer of the oral cavity (38%). Option C, the floor of mouth, is the second most common site (26%). These two sites are followed by all other sites of the mouth: Option D, buccal mucosa (18%); and Option A, the lip (18%). |
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126. Which of the following statements about squamous cell carcinoma of the pyriform sinus is true? A. It has a better prognosis than primary tonsillar carcinoma. B. Otalgia is usually due to involvement of the superior laryngeal nerve. C. Level 3 lymph node involvement in the neck is uncommon. D. The overall risk of lymph node involvement is about 40%. |
Correct answer is B. RATIONALE: This item is important in regard to the management of pyriform sinus cancers. The risk of nodal metastasis is 70%. Primary oropharyngeal carcinoma tends to have a better prognosis. |
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111. Which of the following statements about squamous cell carcinoma of the hypopharynx is true? A. Dysphagia is uncommon after primary radiation therapy is administered for a posterior pharyngeal wall tumor. B. Pyriform sinus tumors are found early due to the development of hoarseness. C. Patients with level 4 lymph node involvement have a worse prognosis. D. The posterior pharyngeal wall is the most common site. |
Correct answer is C. RATIONALE: Squamous cell carcinomas of the hypopharynx are rare, although pyriform sinus cancers are much more common than posterior pharyngeal wall (PPW) cancers and have a late presentation with one of the symptoms being hoarseness related to vocal cord fixation. Outcomes are poor with lower neck involvement, which is important in the era of systemic chemotherapy, possibly requiring induction chemotherapy. Swallowing function can be poor when treating posterior pharyngeal wall (PPW) cancers, including treatment of all the constrictor muscles and the larynx. |
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96. Which of the following factors is associated with the highest risk of treatment failure for patients with squamous cell carcinoma of the head and neck of unknown primary? A. Basaloid differentiation B. Lymphoepithelial histology C. Number of involved lymph nodes D. Extranodal extension |
Correct answer is D. RATIONALE: Extranodal extension is associated with the highest risk of treatment failure for patients with squamous cell carcinoma of the head and neck of unknown primary. |
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72. Which of the following squamous cell carcinomas of the larynx is most appropriate for laryngeal-conserving chemoradiation therapy? A. Glottic primary with decreased cord mobility B. Glottic primary with extension superiorly into the ventricle and false vocal cord C. Suprahyoid epiglottic primary with invasion through the thyroid cartilage D. Supraglottic primary with a fixed cord and preepiglottic space invasion |
Correct answer is D. RATIONALE: Examples that were described in the question included two early-stage larynx cancers (options A and B) that would be treated with radiation therapy alone without the use of systemic therapy. Having a significant involvement of the base of tongue were excluded from larynx preservation trials due to the poor outcomes on the VA larynx study, and the tumor with thyroid cartilage invasion did not go through the cartilage so it still would be a candidate for chemotherapy and radiation therapy, per RTOG 91-11. |
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59. Which of the following radiation treatment approaches is most appropriate for earlystage squamous cell carcinoma of the glottic larynx? A. 63 Gy in 35 fractions to the larynx only B. 63 Gy in 35 fractions to the larynx and level 2-4 lymph nodes C. 63 Gy in 28 fractions to the larynx only D. 63 Gy in 28 fractions to the larynx and level 2-4 lymph nodes |
Correct answer is C. RATIONALE: Stage T1N0 glottic larynx cancers can be treated very well with a hypofractionated course of treatment with randomized data demonstrating better local control. Complication rates are less than 1% for stage T1 tumors, as opposed to stage T2 tumors where the complication rates for severe laryngeal edema have been noted in 4% to 5% of patients. These are all important factors for evaluating patients with larynx cancer. Stage T2 tumors have a 3% to 7% risk of lymph node involvement as opposed to 1% for stage T1 tumors. |
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348. The RTOG 9501/Intergroup Study evaluated the role of postoperative chemotherapy in addition to radiotherapy among high-risk patients with head and neck cancer. Which one of the statements is CORRECT concerning the findings of the study? A. No benefit by adding chemotherapy to adjuvant radiation B. Chemotherapy improved the disease-free survival by reduction of distant metastasis C. Disease-free survival was improved by better local and regional control D. Overall survival was significantly improved |
Answer 348 is C. Both the RTOG and EORTC trials have shown that chemotherapy in addition to postoperative radiotherapy improved disease-free survival for high risk patients by reducing the local and regional failures. (NEJM 350:1937-52, 2004) |
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350. Which one of the following statements is CORRECT about nasopharyngeal carcinoma? A. WHO type I carcinoma commonly has high serologic titers to Epstein-Barr virus B. It is strongly linked to excess use of tobacco and alcohol C. Undifferentiated carcinoma is most common in North America D. WHO type III carcinoma is more radiosensitive than type I |
Answer 350 is D. Undifferentiated carcinoma (WHO type III) is more radiosensitive than squamous cell carcinoma (WHO type I). |
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351. According to RTOG 9111, a phase 3 randomized trial, which one of the following statements is CORRECT regarding the concurrent use of chemotherapy and radiation for patients with locally advanced laryngeal cancers? A. Overall survival was improved with concurrent vs. sequential therapy or radiotherapy alone B. Acute and late toxicities were more significant with concurrent vs. sequential therapy C. Laryngectomy-free survival was significantly improved with the concurrent use of chemotherapy and radiation vs. sequential therapy or radiotherapy alone D. There was no difference in locoregional control between concurrent and sequential use of chemotherapy with radiation |
Answer 351 is C. At two years, LFS with concurrent chemoradiotherapy (88%) differed significantly from the induction chemotherapy followed by radiotherapy group (75%), or radiotherapy alone (70%). The rate of locoregional control was also significantly better with concurrent chemoradiotherapy (78% vs 61% with induction chemotherapy and 56% with radiotherapy alone). The total rates of severe toxic effects (acute and late) reported for all phases of the study were 81% in the group assigned to induction sequential therapy and 82% for patients assigned to concurrent chemoradiotherapy. (NEJM 349(22) 2091-8, 2003.) |
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352. Which one of the following patient or tumor-related factors is the MOST important regarding the risk of lymph node metastases from squamous cell carcinomas of the oral cavity? A. Gender B. Age C. Site D. Thickness of tumor invasion E. Histologic differentiation |
Answer 352 is D. The depth of invasion of oral cavity squamous cell carcinoma has the strongest association with the risk of lymph node metastasis. |
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353. The RTOG 9003 was designed to compare 4 different radiotherapy treatment schedules. Which one of the following statements is CORRECT concerning the benefits of concomitant-boost approach in comparison to conventional fractionation? A. Improved overall survival B. Decreased acute toxicity C. Improved local control D. Increased patient compliance E. Increased late toxicity |
Answer 353 is C. This randomized trial revealed a better local control with concomitant boost (54.5%) at 2 years compared to 46% with conventional fractionation. (Fu KK, Pajak TF, Trotti A. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfrationation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinoma: first report of RTOG 9003. Int J Radiation Oncol Biol Phys. 2000;48:7-16.) |
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301. According to the results of Radiation Therapy Oncology Group (RTOG) 91-11, the rationale for recommending concurrent chemotherapy and radiation therapy for patients with locally advanced squamous cell carcinomas of the larynx is based on improvements in which of the following? A. Disease-free survival B. Overall survival C. Voice preservation D. Rates of distant metastases |
Answer 301 is C. The study was designed with a primary endpoint of laryngectomy free survival, not overall survival. |
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310. A postoperative radiation therapy field is designed to treat a completely resected, high-grade mucoepidermoid carcinoma of the parotid gland. Which of the following anatomic borders is NOT appropriate? A. Superior border at the zygomatic arch B. Inferior border at the inferior border of the mandible C. Anterior border at the second molar to include the Stensen duct D. Posterior border at the mastoid process |
Answer 310 is B. The inferior border should be at the hyoid bone to ensure adequate coverage of the parotid bed. |
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317. Which of the following histologic types of nasopharyngeal cancer has the highest risk of local failure after being treated with radiation therapy? A. Nonkeratinizing carcinoma B. Keratinizing squamous cell carcinoma C. Undifferentiated carcinoma D. Lymphoma |
Answer 317 is B. Compared to other histologic types as listed above, keratinizing squamous cell carcinoma is the least radiosensitive and has the lowest risk for distant failure. |
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319. Which of the following statements about nasopharyngeal angiofibroma is true? A. It is locally invasive. B. It occurs primarily in females. C. It is highly resistant to radiation therapy. D. It is more common in adults than in teenagers. |
Answer 319 is A. Despite benign histology, angiofibroma of the nasopharynx can be locally invasive causing bony erosion to the clivus. |
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320. Which of the following structures involved by a squamous cell carcinoma of the paranasal sinus has the best prognosis? A. Destruction of the roof of the sphenoidal sinuses B. Involvement of the cavernous sinus C. Involvement of the nasal cavity D. Intracranial extension |
Answer 320 is C. Nasal cavity involvement itself does not prevent definitive surgery, which offers the best local control. |
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10. A well-lateralized, stage T3N0 squamous cell carcinoma of the nasopharynx has at least a 15% risk of metastasis to the: A. ipsilateral parotid lymph nodes. B. ipsilateral submandibular lymph nodes. C. posterior triangle lymph nodes bilaterally. D. occipital lymph nodes bilaterally. |
Correct answer is C. RATIONALE: An important concept in the management of nasopharyngeal cancer is the need for elective irradiation of the level V nodes bilaterally, regardless of the status of the neck. The lymph nodes in the other areas are not routinely treated in a patient with a stage N0 neck. |
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22. Which of the following findings is most likely to be caused by loss of function of right cranial nerve XII? A. Deviation of the tongue to the left side with protrusion B. Deviation of the tongue to the right side with protrusion C. Loss of sweet taste on the right side of the tongue D. Loss of salty taste on the right side of the tongue |
Correct answer is B. RATIONALE: Deviation of the tongue to the ipsilateral side is the major finding in a patient with loss of function of cranial nerve XII. |
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36. Which of the following depths of invasion is considered to be the threshold for elective irradiation of the regional lymph nodes in a patient with squamous cell carcinoma of the oral tongue? A. 01.0 mm B. 03.0 mm C. 10.0 mm D. 15.0 mm |
Correct answer is B. RATIONALE: A large number of studies recommend a threshold value of 2 mm to 5 mm depth of invasion for elective treatment of the regional lymph nodes in this setting. |
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49. What is the risk of metastasis to the lymph nodes in a patient with stage T2N0 squamous cell carcinoma of the lateral aspect of the oral tongue? A. There is a greater risk of metastasis to the retropharyngeal nodes than to the mid-jugular nodes. B. There is a greater risk of metastasis to the superior jugular nodes than to the submandibular nodes. C. There is a similar risk of metastasis to the retropharyngeal nodes as to the mid-jugular nodes. D. There is a similar risk of metastasis to the submandibular nodes as to the mid-jugular nodes. |
Correct answer is D. RATIONALE: An important concept in both surgical and radiotherapeutic management of oral tongue cancer is parallel first echelon drainage to the submandibular (level I) and mid-jugular lymph nodes. |
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53. Which of the following factors most adversely affects patients receiving radiation therapy for squamous cell carcinoma of the head and neck? A. Concurrent HPV infection B. Concurrent tobacco use C. Gender of the patient D. Grade of the cancer |
Correct answer is B. RATIONALE: Continued tobacco use by a patient undergoing radiation therapy for head and neck malignancies is well-documented to be associated with poorer tumor control rates, increased side effects, and increased need for treatment breaks. Unlike herpesvirus or HIV infections, human papilloma virus (HPV) infections have not been shown to be associated with increased treatment-related toxicities. |
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61. Which of the following stages of oropharyngeal squamous cell carcinoma is associated with the lowest risk of contralateral cervical lymph node metastases? A. T2N1 with the primary tumor confined to the tonsillar fossa B. T1N1 involving the most lateral section of the soft palate C. T1N1 confined to the glossal-tonsillar sulcus D. T1N0 involving the lateral aspect of the base of tongue |
Correct answer is A. RATIONALE: There are now multiple papers documenting a less than 5% recurrence rate in the contralateral lymph nodes following radiation therapy to the ipsilateral nodes (no treatment to the contralateral nodes) in patients with T1-T2, N0-N2b stage small cell carcinoma that is confined to the tonsillar fossa. The other answers describe situations where the risk of contralateral neck disease is clearly greater than 15%. |
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87. Primary surgery is most appropriate for patients with which of the following types of squamous cell carcinoma? A. Stage T1N0 of the oropharyngeal portion of the posterior pharyngeal wall B. Stage T1N0 of the floor of mouth C. Stage T1N0 of the soft palate D. Stage T2N0 of the base of tongue |
Correct answer is B. RATIONALE: Primary surgery is the recommended therapy for most tumors of the oral cavity, while radiation therapy is preferable to surgery for most tumors of the oropharynx. Even experts who recommend primary surgery for oropharynx primaries would agree that the added benefit from surgery is greatest for answer B. |
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101. What two emission products of 131I are used to manage patients with papillary thyroid carcinoma? A. An electron for radiation therapy and an electron for diagnostic imaging B. An electron for radiation therapy and a photon for diagnostic imaging C. A photon for radiation therapy and an electron for diagnostic imaging D. A photon for radiation therapy and a photon for diagnostic imaging |
Correct answer is B. RATIONALE: Iodine-131 is able to ablate thyroid tissue and tumor cells because it emits a relatively low-energy electron that deposits energy within a few millimeters. Iodine-131 is used to image thyroid cancer because a second emission product is a kilovoltage-range photon that exits the body. |
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119. Which of the following lesions is most likely to be associated with otalgia? A. Stage T1N1 of the base of tongue B. Stage T1N1 of the posterior pharyngeal wall of the hypopharynx C. Stage T2N0 of the middle section of the hard palate D. Stage T2N1 of the true vocal cord |
Correct answer is A. RATIONALE: Earache is a common symptom at diagnosis of carcinoma of the base of tongue or supraglottic larynx. The mechanism for ear pain in this setting is referred pain along the nerves of Jacobson and Arnold. |
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127. A 35-year-old woman who has follicular thyroid carcinoma undergoes thyroidectomy and neck dissection, which reveals positive margins and lymph nodes. Which of the following radiation therapy plans is most appropriate? A. A 150-mCi dose of 131I, followed by external-beam radiation therapy to a dose of 50 Gy at 2 Gy per fraction B. External-beam radiation therapy to a dose of 50 Gy at 2 Gy per fraction, followed by a 150-mCi dose of 131I C. External-beam radiation therapy to a dose of 70 Gy at 2 Gy per fraction only D. A 150-mCi dose of 131I only |
Correct answer is D. RATIONALE: In a young adult, the only conceivable indication for external-beam radiation therapy is recurrent disease following I-131 therapy. This patient does not have an indication for external-beam radiation therapy. |
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136. Which of the following results is associated with concurrent chemoradiation therapy versus radiation therapy alone for patients with locally advanced laryngeal cancer, based on the RTOG 91-11 study? A. Same rate of distant metastases B. Improved swallowing function C. Improved overall survival D. Improved local control |
Correct answer is D. RATIONALE: Based on results of the RTOG 91-11 study. |
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176. Which of the following statements about the EORTC hypopharynx preservation trial is true? A. Fifty percent of the patients had primary tumors involving the pyriform sinus. B. The overall survival at 5 years revealed a significant improvement associated with chemotherapy, followed by radiation therapy. C. Only patients with a complete clinical response after induction chemotherapy were eligible for definitive radiation therapy. D. Patients with palpable adenopathy were required to undergo neck dissections following completion of radiation therapy. |
Correct answer is C. RATIONALE: This is one of the fundamental differences between this trial and the VA laryngeal preservation study. Patients were required to have achieved a clinical complete response to induction chemotherapy prior to undergoing radiation therapy. |
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182. Which of the following statements about squamous cell carcinoma of the larynx is true? A. Primary tumors more commonly arise from the supraglottic laryngeal structures than from the glottic region. B. At the time of diagnosis, 50% of tumors have extended beyond the laryngeal structures. C. Supraglottic tumors are more likely to present with palpable lymphadenopathy than glottic lesions. D. Subglottic tumors tend to present with early lesions that are easily managed with primary surgical resection. |
Correct answer is C. RATIONALE: Glottic lesions have a lower chance than supraglottic lesions of spreading to the lymph nodes, because the true vocal cords have essentially no capillary lymphatics. In fact, there is a 20% chance that patients with stage T3 and T4 glottic cancers will have clinically involved lymph nodes at initial presentation; whereas, there is a 55% chance that patients with stage T1-T4 supraglottic cancer will have clinically positive lymph nodes at diagnosis. |
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190. Which of the following subsites of the hypopharynx is correctly ordered from the least to the most commonly involved sites? A. Pyriform sinus, posterior pharyngeal wall, postcricoid region B. Posterior pharyngeal wall, postcricoid region, pyriform sinus C. Posterior pharyngeal wall, pyriform sinus, postcricoid region D. Postcricoid region, posterior pharyngeal wall, pyriform sinus |
Correct answer is D. RATIONALE: Postcricoid region tumors are not very common. Pyriform sinus cancers are more common than posterior pharyngeal tumors. |
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204. Which of the following factors is NOT typically associated with improved overall survival for patients who present with unknown primary tumors of the head and neck region? A. Radiation doses of >50 Gy B. Complete resection of the involved lymph nodes C. Subsequent presentation of the primary tumor D. Stage N1 versus stage N2 lymph node involvement |
Correct answer is C. RATIONALE: The subsequent development of a primary tumor in a patient who has undergone postoperative radiation therapy portends a worse prognosis. |
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218. Which of the following statements about unknown primary head and neck tumors is true? A. PET imaging is able to detect the primary tumor in 60% of cases. B. Random biopsies will reveal the primary lesion in 40% of cases. C. Chest imaging will reveal a primary lung tumor in 20% of cases. D. Tonsillectomy may reveal the occult primary tumor in 20% of cases. |
Correct answer is D. RATIONALE: A tonsillectomy can reveal occult primary tumors in 20% of cases. A PET scan is able to detect the primary tumor in approximately 15% to 20% cases only. |
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234. Adverse predictors of overall survival for patients with parotid gland malignancies include all of the following factors EXCEPT: A. deep lobe lesion. B. acinic cell histology. C. high-grade mucoepidermoid histology. D. facial nerve paralysis. |
Correct answer is B. RATIONALE: Acinic cell histology is not an adverse factor because it is a low-grade tumor. |
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355. Which of the following statements about the effectiveness of 131I for treating thyroid cancer is true? A. Medullary carcinoma is treated more effectively than Hürthle cell carcinoma. B. The follicular variant of papillary carcinoma is treated more effectively than Hürthle cell carcinoma. C. Tall cell carcinoma is treated more effectively than the follicular variant of papillary carcinoma. D. Insular carcinoma is treated more effectively than the follicular variant of papillary carcinoma. |
Correct answer is B. RATIONALE: The follicular variant of papillary carcinoma concentrates radioiodine as well as any other well-differentiated variant. The other variants listed above are unfavorable because they concentrate radioiodine poorly or not at all. Many experts do not recommend the use of radioiodine therapy for Hürthle, tall, insular, or medullary carcinoma. |
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9. Which of the following retropharyngeal lymph nodes should be treated in a patient with stage T1N0M0, well lateralized, squamous cell carcinoma of the roof of the nasopharynx? A. Bilateral medial and lateral nodes B. Bilateral lateral nodes only C. All ipsilateral and medial contralateral nodes D. All ipsilateral nodes only |
Correct answer is A. RATIONALE: The risk of disease in all sections of the retropharyngeal lymph nodes is high enough that all groups should be treated bilaterally in all cases of nasopharynx cancer. The question of sparing the medial group of lymph nodes applies to patients with oropharynx cancer. |
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17. According to an EORTC study, the use of induction chemotherapy for patients with hypopharynx cancer resulted in a 5-year actuarial voice preservation rate of: A. 15%. B. 35%. C. 50%. D. 70%. |
Correct answer: ABCD. Reference: Journal of the National Cancer Institute. 1996;88:890. |
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25. Which of the following chemotherapy regimens has NOT been shown to improve patient outcomes when combined with radiation therapy compared to radiation therapy alone in a phase III study of patients with squamous cell carcinomas of the head and neck? A. Carboplatin and paclitaxel B. Carboplatin and 5-FU C. Cisplatin D. Cetuximab |
Correct answer is A. RATIONALE: Even though the combination of carboplatin and paclitaxel is a very common chemotherapy regimen used in various intergroup studies as well as in the community for patients with squamous cell carcinomas of the head and neck, it has never been tested in a phase III trial over the use of radiation therapy alone. Cisplatin has been the most widely tested systemic agent for daily, weekly, and 3-week cycle therapy in combination with radiation therapy. Cetuximab has recently obtained FDA approval in the treatment of patients with metastatic as well as locally advanced cancers of the head and neck. |
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27. Which of the following statements about optic pathway gliomas is FALSE? A. The majority of these tumors involve one optic nerve only. B. The clinical course of these tumors is more indolent if associated with NF-1. C. The most common histology associated with these tumors is WHO grade 1 astrocytoma. D. The recommended radiation dose is 45 Gy to 50 Gy. |
Correct answer is A. RATIONALE: Only about 10% of optic pathway gliomas are located in one optic nerve; one third of the tumors involve both optic nerves and chiasm; another one third of the tumors involve the chiasm alone; and one fourth of the tumors involve the hypothalamus alone. |
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38. Which of the following treatment strategies could improve the therapeutic ratio for head and neck cancer? A. Giving one or two hyperthermia treatments 1 week before the start of radiation therapy B. Using hyperfractionation instead of conventional fractionation to try to reduce the frequency of late effects C. Using hypofractionation instead of conventional fractionation to try to reduce the frequency of late effects D. Adding a hypoxic cell radiosensitizer in the case of a small, well-aerated tumor |
Correct answer is B. RATIONALE: In most cases, hyperfractionation would be expected to differentially spare late-responding normal tissues relative to the tumor and, as such, would be the only treatment scenario listed that would improve the therapeutic ratio for head and neck cancer. Hypofractionation would likely have the opposite, undesirable effect of increasing the likelihood of late complications in the head and neck region. Hypoxic cell radiosensitizers would have little or no effect on tumors that do not contain hypoxic cells (nor on well-aerated normal tissues). The radiosensitizing effect of heat is most evident when hyperthermia and radiation are applied simultaneously (or nearly so), not 1 week apart. |
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56. Which of the following statements about the EORTC study of larynx preservation in hypopharynx cancer is true? A. The majority of patients in the study had stage T4 disease. B. A complete response to chemotherapy was required for patients to avoid surgery and receive radiation therapy alone. C. Induction chemotherapy provided a statistically significant overall survival benefit. D. The induction chemotherapy regimen consisted of docetaxel, cisplatin, and 5-FU. |
Correct answer is B. Reference: Journal of the National Cancer Institute. 1996;88:890. |
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58. Compared to 3D conformal treatment, IMRT demonstrates the greatest improvement in conformality for patients with: A. Hodgkin's lymphoma. B. nasopharyngeal cancer. C. breast cancer. D. skin cancer. |
Correct answer is B. RATIONALE: IMRT has the advantage of yielding extremely conformal dose distributions, even for very concave shapes, which is difficult to achieve with 3D conformal treatment. Of the options listed, IMRT has demonstrated a marked improvement in the dose distribution and conformality for head and neck cases, such as nasopharyngeal cancers. |
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72. Which of the following statements about the AJCC tumor staging system for hypopharynx cancer is true? A. Stage T1 involves a 1.5-cm tumor limited to the pyriform sinus only. B. Stage T1 involves a 1.5-cm tumor involving the pyriform sinus and hypopharyngeal wall. C. Stage N1 involves a single ipsilateral lymph node more than 3 cm but less than 6 cm. D. Stage N3 involves a single ipsilateral supraclavicular lymph node smaller than 3 cm. |
Correct answer is A. RATIONALE: To be considered stage T1, a tumor must be limited to one subsite and measure 2 cm or less. Reference: AJCC Cancer Staging Manual, 6th edition. |
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87. Which of the following situations is most likely to compromise the effectiveness of 131I therapy (150 mCi) after thyroidectomy for papillary thyroid cancer? A. Serum TSH level of 60 U/mL during 131I administration B. Serum TSH level of 30 U/mL during 131I administration C. Chest CT scan with iodinated IV contrast 1 month before 131I therapy D. 99mTc bone scan 1 month before 131I therapy |
Correct answer is C. RATIONALE: Iodinated IV contrast compromises the efficacy of 131I therapy for months. |
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103. Which of the following bones forms the roof of the nasopharynx? A. Pterygoid plate B. Lesser wing of the sphenoid C. Vomer D. Clivus |
Correct answer is D. RATIONALE: The clivus is the bone that forms the roof of the nasopharynx. |
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109. A patient with right maxillary sinus cancer has a tumor extending into the floor of the orbit. The AJCC stage of this tumor is: A. T2. B. T3. C. T4a. D. T4b. |
Correct answer is B. Reference: AJCC Cancer Staging Manual, 6th edition. |
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111. Which of the following four structures are all located in the oropharynx? A. Vallecula, uvula, glossotonsillar sulcus, anterior tonsillar pillar B. Vallecula, retromolar trigone, hard palate, anterior tonsillar pillar C. Uvula, Stenson's duct opening, glossotonsillar sulcus, anterior tonsillar pillar D. Wharton's ducts opening, glossotonsillar sulcus, soft palate, posterior tonsillar pillar |
Correct answer is A. RATIONALE: Options B, C, and D contain a structure that is in the oral cavity. |
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126. Which of the following lines divides the maxillary sinus into the suprastructure and infrastructure? A. Ohngren B. Rouviere's C. Fletcher's D. Grey's |
Correct answer is A. Reference: AJCC Cancer Staging Manual, 6th edition. |
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156. Compared to conventional radiation therapy, IMRT offers which of the following benefits for treatment of squamous cell carcinomas of the head and neck? A. IMRT decreases the incidence of acute side effects. B. IMRT decreases the risk of late xerostomia when the parotid gland is spared. C. IMRT decreases the radiation dose to the larynx in patients with squamous cell carcinoma of the tonsil. D. IMRT improves local control in early-stage oropharynx cancers. |
Correct answer is B. RATIONALE: It is important to understand that IMRT does not decrease the incidence of acute side effects. IMRT can increase toxicity related to more heterogeneity in surrounding normal structures. The clear benefit of IMRT appears to be decreased risk of late xerostomia. The control rates for small oropharynx cancers are already excellent, and IMRT will not be able to improve on these already excellent results. |
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181. Which of the following squamous cell carcinomas of the head and neck has the lowest risk for contralateral lymph node involvement? A. T1N0 of the nasopharynx B. T1N0 of the base of tongue C. T2N0 of the tonsillar fossa D. T3N0 of the pyriform sinus |
Correct answer is C. RATIONALE: T2N0 of the tonsillar fossa when it does not have extension to the soft palate or base of tongue has a less than 10% risk of contralateral lymph node involvement, based on the data from Bryan O'Sullivan at Princess Margaret discussing ipsilateral radiation for patients with tonsillar cancer. |
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196. Which of the following signs is associated with a unilateral cranial nerve XII (hypoglossal nerve) deficit? A. Loss of taste on the ipsilateral side of the tongue B. Deviation of the tongue to the contralateral side with protrusion C. Deviation of the tongue to the ipsilateral side with protrusion D. Numbness on the ipsilateral side of the tongue |
Correct answer is C. RATIONALE: Protrusion to the ipsilateral side is the sign of a unilateral cranial nerve XII deficit. In hypoglossal nerve deficit, the tongue deviates toward the healthy side at rest and toward the affected side on protrusion. |
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225. Which of the following structures comprises the lateral border of the nasal vestibule? A. Membranous septum B. Columella C. Choana D. Nasal ala |
Correct answer is D. Reference: Grant's Anatomy book. |
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237. Which of the following structures would NOT be affected by a tumor in the parapharyngeal space? A. Facial nerve B. Vagus nerve C. Accessory nerve D. Internal carotid artery |
Correct answer is A. RATIONALE: It is important to know what cranial nerve deficits could appear for tumors in the parapharyngeal space, which includes cranial nerves IX, X, XI, and XII. In addition, important blood vessels including the internal carotid artery, external carotid artery, as well as the internal jugular vein also transverse this important space. |
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242. Which of the following combinations of chemotherapy with irradiation of the cochlea is most likely to cause high-frequency hearing loss? A. Carboplatin, etoposide, bleomycin, and >20-Gy radiation dose B. Carboplatin, etoposide, cyclophosphamide, and >20-Gy radiation dose C. High-dose methotrexate, intrathecal methotrexate, and >30-Gy radiation dose D. Cisplatin, etoposide, vincristine, and >30-Gy radiation dose |
Correct answer is D. RATIONALE: This question is asking two questions. The combination of chemotherapy agents (cisplatin, etoposide, vincristine) and the dose of irradiation (>30 Gy) delivered to the cochlea that most commonly will cause high-frequency hearing loss. |
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243. Which of the following statements about tumors of the salivary gland is true? A. Masses in the parotid gland are more likely to be malignant than masses in the submandibular or sublingual glands. B. Tumors of the major salivary gland are more likely to be malignant than tumors of the minor salivary glands. C. Facial nerve paralysis is a common presentation for patients with adenoid cystic carcinomas of the parotid gland. D. Ex pleomorphic adenoma is the most common malignancy of the parotid gland. |
Correct answer is C. RATIONALE: It is important to understand various aspects of management of patients with salivary gland tumors, as well as some other presenting symptoms that are classic for adenoid cystic carcinomas. |
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249. Which of the following statements about cetuximab is true? A. Combining it with radiation therapy improves overall survival. B. Combining it with radiation therapy significantly increases the risk for development of mucositis compared to radiation therapy alone. C. It is a monoclonal antibody to the vascular epithelial growth factor. D. Lymphopenia is the most common side effect. |
Correct answer is A. RATIONALE: There are several potential advantages of the use of cetuximab over more conventional cytotoxic therapies in that the typical rate-limiting toxicity of mucositis in radiation therapy has not been shown (in the Bonner study) to increase when combined with radiation therapy alone. Cetuximab is a monoclonal antibody to epidermal growth factor receptor (EGFR) not vascular endothelial growth factor (VEGF), and it is also important to understand that the majority of patients in this trial were not treated with conventional fractionation schemes. Three fourths of the patients were treated with altered fractionation. The majority of patients were treated with concomitant boost radiation therapy. |
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265. Postoperative chemoradiation is LEAST effective for patients with which of the following squamous cell carcinomas of the head and neck? A. Stage T1N1 of the oral tongue with a 1.5-cm lymph node that demonstrated extracapsular extension B. Stage T2N0 of the oral tongue with a positive margin C. Stage T3N0 of the glottic larynx treated with a total laryngectomy and lymph node dissection, with negative margins and no lymph node involvement D. Stage T3N2b of the tonsillar fossa treated with tonsillectomy, with gross residual disease at the tonsillar fossa in the surgical bed and two ipsilateral lymph nodes in the neck dissection specimen |
Correct answer is C. RATIONALE: There have been two prospective trials evaluating the benefit of cisplatin in addition to radiation therapy to the postoperative bed and regional lymph nodes published in the last several years. Due to the differences in the entry criteria of the two studies, the two intergroups involved combined their data and reevaluated where the largest survival benefits were limited to patients with extracapsular extension and involved surgical margins, while no other subgroup demonstrated a survival advantage. Therefore, even though a T3 glottic larynx cancer met the entry criteria for the European study, the subset analysis did not demonstrate a benefit in this group. |
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295. A 45-year-old man presents with a 3-cm right jugulodigastric neck mass. The patient does not smoke or drink alcohol. Fine-needle aspiration of the neck mass reveals squamous cell carcinoma. The most likely location of the primary tumor is the: A. tonsil. B. epiglottis. C. nasopharynx. D. pyriform sinus. |
Correct answer is A. RATIONALE: A University of Florida series on unknown primary cancers showed that the most common primary tumor location for a patient with squamous cell carcinoma of the jugulodigastric neck was the tonsillar fossa (Head & Neck. 1998;20:739.). Patients without a tobacco or alcohol history often have HPV-associated oropharynx cancer, which is also more common in younger patients. Reference: Clinical Cancer Research. 2002;9:3187. |
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331. Which of the following structures is located in the oral cavity? A. Anterior tonsillar pillar B. Anterior half of the soft palate C. Retromolar trigone D. Base of tongue |
Correct answer is C. RATIONALE: The retromolar trigone is located in the oral cavity. |
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352. Which of the following patients has the strongest indication for external-beam radiation therapy immediately after thyroidectomy and lymph node dissection for papillary thyroid cancer? A. A 26-year-old woman who has stage T4N0 disease with a positive margin on the trachea B. A 26-year-old woman who has stage T3N1b disease, based on multiple positive lymph nodes in levels III and IV bilaterally C. A 65-year-old man who has stage T4N0 disease with a positive margin on the trachea D. A 65-year-old man with stage T3N1b disease, based on multiple positive lymph nodes in levels III and IV bilaterally |
Correct answer is C. RATIONALE: The constellation of age greater than 50 years, male gender, stage T4 primary, and positive margin is by far the worst prognostic group. |
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6. What is the threshold dose for dysphagia from radiation therapy to the superior constrictor muscles? A. 75 Gy B. 65 Gy C. 55 Gy D. 45 Gy Correct answer is C. RATIONALE: The answer to this item is based on tolerance doses established from MSKCC and multiple ASTRO 2007 abstracts. 17. What is the best time after surgery to initiate a 7-week course of conventional fractionated radiation therapy for high-risk patients with advanced head and neck cancer? A. 04 weeks B. 08 weeks C. 10 weeks D. 12 weeks |
Correct answer is A. RATIONALE: This item is based on Ang's 2004 International Journal of Radiation Oncology, Biology, Physics (IJROBP) paper showing that the optimal treatment duration is 11 weeks (ie, 7-week radiation course delivered 4 weeks after surgery = 11 weeks) for high-risk patients with advanced head and neck cancer. |
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25. Which of the following sites is most commonly associated with HPV-induced squamous cell carcinoma? A. Hypopharynx B. Oropharynx C. Nasopharynx D. Larynx |
Correct answer is B. Site of cancer % of +HPV-16 DNA Hypopharynx 0% Oropharynx 50% Nasopharynx 14% Larynx 3% REFERENCE: Jon Mork, et al. New England Journal of Medicine (NEJM). 2001;344,15:1125-31. |
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31. Which of the following stages of oropharyngeal cancer can be adequately treated with unilateral therapy? A. T1N1 of the tonsil B. T1N2a of the tonsil C. Lateralized T2N0 of the base of tongue D. T3N0 of the tonsil |
Correct answer is A. RATIONALE: Based on Princess Margaret Hospital experience reported by O' Sullivan. REFERENCE: International Journal of Radiation Oncology, Biology, Physics (Int. J. Radiation Oncology Biol. Phys.). 2001;51(2):332–343. |
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41. Which of the following treatment plans is best for a patient with stage T1 squamous cell carcinoma of the glottic larynx? A. 79.2 Gy in 66 fractions of 1.2 Gy administered twice daily B. 63 Gy in 28 fractions of 2.25 Gy C. 63 Gy in 35 fractions of 1.8 Gy D. 60 Gy in 30 fractions of 2.0 Gy, plus cisplatin |
Correct answer is B. RATIONALE: Choice B is the current "gold standard." Choice A has been shown to be inferior. Choice C is acceptable for stage T2, but not stage T1. Choice D is much too aggressive. |
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48. Which of the following sites should be included in radiation therapy for a stage T3 squamous cell carcinoma of the hypopharynx? A. Superior retropharyngeal lymph node (Rouvière node) B. Pterygomandibular raphe C. Level VI lymph nodes D. Meckel's cave |
Correct answer is A. RATIONALE: Carcinomas of the hypopharynx drain into the retropharyngeal nodes, and they should be covered to the base of the skull. Meckel's cave should be covered when treating cancer with perineural invasion of the trigeminal nerve. |
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61. Overexpression of p16 in HPV-associated oropharyngeal squamous cell carcinoma is an independent prognostic factor for: A. lower disease-free survival. B. higher overall survival. C. higher local recurrence. D. higher response rate to EGFR-targeted therapy. |
Correct answer is B. RATIONALE: In patients with oropharyngeal squamous cell carcinoma, overexpression of p16 (a subtype of HPV) has been shown to be an independent prognostic factor for local recurrence, disease-free survival, and overall survival. REFERENCE: Weinberger, et al. Clinical Cancer Research. September 1, 2004;10:5684-5691. |
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71. The administration of concurrent cisplatin-based chemotherapy with radiation therapy for head and neck cancer has been shown to decrease: A. distant metastases. B. locoregional recurrence. C. acute toxicity. D. late toxicity. |
Correct answer is B. RATIONALE: All trials supporting chemoradiotherapy show an improvement in locoregional control. Very few also show an effect on distant disease. Toxicity is greater with concurrent chemotherapy and radiation therapy, and there is no logic to decreasing the dose of radiation therapy since it is the most effective "drug" we have. |
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89. Which of the following statements about the use of radioactive iodine for patients with thyroid malignancies is true? A. Iodine imaging should be performed before ablation of the thyroid remnant after surgery. B. Typically, iodine imaging should be performed within 1 month after CT scans with IV contrast. C. A high level of thyroxin is necessary before iodine imaging. D. The typical dose of radioactive iodine therapy is between 50 and 100 mCi. |
Correct answer is A. RATIONALE: It is important to understand how and when to use iodine imaging. Prior to iodine imaging, a high level of TSH is necessary for an optimal uptake of radiolabeled iodine. |
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130. Which of the following pathologic factors is an absolute indication for concurrent adjuvant chemoradiation for high-risk patients with advanced head and neck cancer? A. Multiple positive lymph nodes B. Extracapsular extension C. Lymphvascular invasion D. Perineural invasion |
Correct answer is B. RATIONALE: This item is based on the EORTC and RTOG high-risk postoperative trials (i.e., the results of RTOG 95-01 and EORTC 22931). The initial results of RTOG 95-01 would support options A or B, but EORTC 22931 would not support option A, and the joint analysis supports only the correct answer (option B). |
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143. Which of the following statements about the use of chemotherapy in addition to radiation therapy for squamous cell carcinoma of the head and neck is true? A. Neoadjuvant chemotherapy is superior to concomitant chemotherapy. B. Polychemotherapy is more effective than monochemotherapy. C. The effect of chemotherapy on patient survival significantly decreases with increasing age. D. The absolute benefit of concurrent chemotherapy is less than 5%. |
Correct answer is C. RATIONALE: Based on the recently updated meta-analysis of chemotherapy in head and neck cancer (MACH0NC), concomitant chemotherapy was most effective when compared to neoadjuvant and adjuvant chemotherapy with an absolute survival benefit of 8% at 5 years. No significant difference was seen between monochemotherapy and polychemotherapy. For the effect of chemotherapy on survival by covariate values (sex, age, performance status, tumor stage, nodal stage, overall stage, and tumor site), the only significant interaction was a decreasing effect of chemotherapy with increasing age (test for trend, p=0.003). REFERENCE: International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 2007;69:112-114. |
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153. Which of the following statements about the use of cetuximab for squamous cell carcinoma of the head and neck is true? A. It should be given after completion of radiation therapy. B. It should be initiated simultaneously with radiation therapy. C. A loading dose is required 1 week before beginning radiation therapy. D. It is more effective when given every 3 weeks rather than weekly. |
Correct answer is C. RATIONALE: A loading dose of 400 mg/M2 should be given 1 week before beginning radiation therapy to saturate the EGFR, and then given weekly during the course of radiation therapy. REFERENCE: Bonner, et al. New England Journal of Medicine (NEJM). 354(6):567-8. |
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169. Which of the following radiation sensitizers combined with postoperative radiation therapy has been shown to improve the outcome of high-risk patients with advanced head and neck cancer? A. Cisplatin every 3 weeks B. Mitomycin and cisplatin every 3 weeks C. Cetuximab weekly D. Cisplatin weekly |
Correct answer is A. RATIONALE: This item is based on the EORTC and RTOG high-risk postoperative trials (ie, RTOG 95-01 and EORTC 22931). |
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178. Based on a pooled analysis, which of the following statements about the addition of high-dose cisplatin with radiation therapy in postoperative patients with high-risk head and neck cancer is FALSE? A. It improves overall survival. B. It improves locoregional control. C. It increases disease-free survival. D. It decreases distant metastasis. |
Correct answer is D. RATIONALE: Based on high-risk EORTC and RTOG postoperative trials, there is no difference in distant metastasis between the two arms. |
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199. The concurrent addition of cetuximab to radiation therapy for squamous cell carcinoma of the head and neck significantly increases: A. oral mucositis. B. overall survival. C. disruption of radiation therapy. D. treatment-related diarrhea. |
Correct answer is B. RATIONALE: The concurrent use of cetuximab with radiation therapy demonstrated significantly improved median survival, overall survival, and locoregional control. It also resulted in acneiform rash, but not oral mucositis. REFERENCE: Bonner, et al. New England Journal of Medicine (NEJM). 354:6.567-8. |
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114. Which of the following is correct regarding Masaoka staging for thymomas? (A) Stage I: Microscopic capsular involvement (B) Stage IIA: Invasion into surrounding fat or invasion into mediastinal pleura (C) Stage III: Extension to surrounding organs or great vessels (D) Stage IVA: Lymph node involvement |
Key: C Rationale: Stage I is encapsulated tumors without microscopic capsular invasion. Stage IIA is microscopic capsular involvement. Invasion into surrounding fat is stage IIB. Stage IVA is pleural or pericardial involvement, but any lymph node involvement (including distant metastasis) is considered stage IVB. |
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288. The expected 3-year survival rate for a 55-year-old male, a never smoker with a p16 (+) T3N2bM0 squamous cell carcinoma of tongue base is: (A) 30%. (B) 50%. (C) 70%. (D) 90%. |
Key: D Rationale: This patient has a p16 positive squamous carcinoma of the oropharynx and has never smoked. Data from prospective studies (1,2) showed that the prognosis in this highly favorable subset of cases, even with stage III and IV disease is excellent with over 90% 3-year survival. There is a strong agreement between tumor HPV status as determined by in situ hybridization and expression of biomarker p16. Tumor p16 status is a well-established prognostic factor in oropharyngeal cancers (2). References: Fakhry C, Westra WH, Li S, et al. Improved Survival of Patients With Human Papillomavirus – Positive Head and Neck Squamous Cell Carcinoma in a Prospective Clinical Trial. J Natl Cancer Inst 2008; 100: 261-269. Ang KK, Harris J, Wheeler R, et al. Human Papillomavirus and Survival of Patients with Oropharyngeal Cancer. N Engl J Med 2010; 363:24-35. |
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299. What is the MOST common histology for tumors of the ethmoid sinus? (A) Adenocarcinoma (B) Esthesioneuroblastoma (C) Adenoid cystic carcinoma (D) Squamous cell carcinoma |
Key: D References: Devita textbook. 113. Which of the following is a contraindication for larynx-preservation with chemoradiation? (A) Paraglottic space invasion (B) Invasion through the thyroid cartilage (C) Involvement of vallecula (D) Impaired vocal cord mobility Key: B Rationale: Refer to the Intergroup trial eligibility. Forastiere AA et al. N Engl J Med. 2003 Nov 27; 349(22):2091-8. |
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211. Which of the following histologies of thyroid cancer is most likely to take up iodine? A. Hürthle cell carcinoma B. Tall cell variant of papillary carcinoma C. Anaplastic carcinoma D. Follicular carcinoma |
Correct answer is D. RATIONALE: It is very important to determine which histologies are likely to take up iodine so appropriate treatment can be initiated. |
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236. Which of the following statements about the treatment of paraganglioma is true? A. A radiation dose of 45 Gy should offer a local control rate of >80%. B. A complete response is common following external-beam radiation therapy. C. Stereotactic radiosurgery is contraindicated. D. Regional lymph nodes should be electively irradiated. |
Correct answer is A. RATIONALE: It is important to understand the effect of treatment, the appropriate dose, and volume for this very curable benign tumor. Local control rates with external-beam radiation were reported ranging from 65% to 100% with a mean of 90%. However, a complete response is uncommon. Most patients will have stable disease after radiation therapy. Stereotactic radiosurgery has been used in the primary treatment of paragangliomas with a dose ranging from 12 to 18 Gy. Lymph node metastasis is extremely rare for paragangliomas. |
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258. The RTOG 91-11 trial showed that concurrent chemoradiation: A. increased severe late toxicity compared to radiation therapy alone. B. increased local control by approximately 20% compared to radiation therapy alone. C. had an equal larynx preservation rate compared to sequential chemoradiation. D. had the same rate of mucositis compared to sequential chemoradiation. |
Correct answer is B. RATIONALE: Concurrent chemoradiation is more effective than radiation therapy (RT) alone in preserving the larynx (approximately 78% vs 56% at 2 years). It is important for radiation oncologists to appreciate the relative magnitude of this improvement. Also, this trial is unique in showing an effect of concurrent chemoradiation on distant metastases. |
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290. Which of the following statements about thyroid malignancies is true? A. Papillary carcinoma spreads most commonly to level 2 lymph nodes. B. Older patients with papillary carcinoma have a better prognosis than younger patients. C. Tumor size is the most important prognostic factor for a resectable follicular cancer. D. Hürthle cell carcinoma has a worse prognosis than other well-differentiated malignancies. |
Correct answer is D. RATIONALE: The rationale for this question is to demonstrate the importance of age and certain pathologies in the prognosis of patients with thyroid malignancies. Hürthle cell cancer has a decreased avidity for 131I; therefore, treatment with radioactive iodide has a limited efficacy. Hürthle cell cancer reportedly behaves in a more aggressive fashion than other well-differentiated thyroid cancers, with a tendency to have a higher incidence of metastasis and a lower survival rate. This is truer for the lesions that are clearly demonstrated to be malignant and in patients who are considered to be at high risk based on such factors as age, tumor size, invasiveness, and the presence of metastasis. Widely invasive tumors behave more aggressively. Recurrence among patients with Hürthle cell carcinoma is considered to be incurable. |
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337. IMRT does NOT decrease the incidence of which of the following complications of nasopharyngeal cancer? A. Dysphagia B. Xerostomia C. Hearing loss D. Osteoradionecrosis |
Correct answer is D. RATIONALE: Dose constraints have been established for salivary gland, cochlea, and constrictor muscles. |
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357. What is the most likely site of origin for an "unknown primary" head and neck tumor associated with the human papillomavirus? A. Oral cavity B. Oropharynx C. Nasopharynx D. Hypopharynx |
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