FC Rad Onc (SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the
College of Radiation Oncologists of South Africa

17 March 2014
Paper 1 Tumour Pathology and General Oncology (3 hours)

All questions to be answered. Each question to be answered in a separate book (or books if more than one is required
for the one answer)

Question 1

a) A 54-year-old male patient with Stage IIIB Non Small Cell Lung Ca is earmarked for
palliative chemotherapy with a cisplatin doublet.
i) List 3 pathophysiological mechanisms of chemotherapy induced nausea and vomiting
(CINV). (3)
ii) List 2 neurotransmitter-receptor pathways that can be targeted for prevention of CINV.
(2)

b) i) List 3 modalities for SRS(Stereotactic radiosurgery) delivery. List at least one
advantage and one disadvantage for each modality. (6)
ii) Tabulate the differences between 3D Conformal Radiotherapy and SRS under the
following headings
i. Treatment delivery.
ii. Dosing and fractionation.
iii. Treatment delivery duration.
iv. Mechanism of cell death. (8)

c) i) What is the role of an online electronic portal imaging device (EPID) in the radiotherapy
treatment process? (2)
ii) How has the utilisation of the EPID improved on the traditional portal image? (1)

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iii) What is cone-beam CT? (1)
iv) How does the assessment of a patient with an EPID image differ compared to
assessment done with a cone beam CT? (2)
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Question 2

a) A 44-year-old female with carcinoma of the left breast is referred after wide local excision
and sentinel lymph node biopsy. Pathological stage is T1cN0M0. She is hormone receptor
negative and Her 2 Neu positive. Adverse pathological features include Ki 67 = 54%, poorly
differentiated tumour with lymphovascular invasion. She is for adjuvant anthracycline-based
chemotherapy and trastuzumab.
i) Briefly describe the mechanism of anthracycline-induced cardiotoxicity. (1)
ii) How does anthracycline-induced cardiotoxicity differ from trastuzumab-induced
cardiotoxicty? (1)
iii) What is the recommended maximum lifetime cumulative dose of doxorubicin? (1)
iv) Discuss preventative measures for anthracycline- induced cardiotoxicity? (5)

b) After 6 cycles of adjuvant chemotherapy, she is for adjuvant breast radiotherapy.
i) List 3 possible radiotherapy treatment techniques that could be used to reduce
radiation- induced cardiotoxicity. (3)
ii) After her external beam RT you plan to give her a tumour bed boost to a depth of 3.4cm.
She will be CT planned
i Describe your CTV and PTV. (2)
ii Write your full boost dose prescription including approximate energy of beam.(3)

c) This patient is deemed suitable for accelerated partial breast irradiation (APBI).
i) Describe APBI. (2)
ii) List 2 possible techniques for administration of APBI. (2)
iii) Name 1 advantage and 1 disadvantage of APBI over conventional external beam
radiotherapy. (2)



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d) Three months post adjuvant therapy, the patient presents with amenorrhoea and hot
flushes. Blood tests show a picture compatible with chemotherapy- induced menopause. A
bone mineral densitometry is done.
i) What test should be done to evaluate osteoporosis and what T-score value would be
consistent with osteoporosis? (2)
ii) What is the general mechanism of action for bisphosphonates in osteoporosis? (1)
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Question 3

a) In 2010, the WHO introduced a new classification of neuro-endocrine tumours. This forms
the basis of clinical decision-making in this disease entity.
i) Give the broad classification of neuro-endocrine tumours. (4)
ii) For irresectable neuro-endocrine tumours, give the primary systemic treatment you
would use for each of the main groups mentioned above. (3)

b) i) Describe the two genes that are most commonly mutated in gastrointestinal stromal
tumours.(GISTs) (2)
ii) Briefly discuss how mutational status would predict response to treatment with tyrosine
kinase inhibitors? (2)

c) i) Describe factors that are associated with increased risk of recurrence in patients with
resected stage II adenocarcinoma of the colon. (3)
ii) How would these affect your treatment? (2)
iii) Which pathological prognostic factor can be used in stage II adenocarcinoma of the
colon? Would the presence of this factor affect post-operative treatment? (2)

d) i) What is the significance of the K-RAS mutation in Colorectal cancer? (2)
ii) Briefly explain the pathophysiology of how EGFR (epidermal growth factor receptor)
upregulation influences the development of certain cancers. (3)
iii) Apart from colorectal cancer, name 2 other cancers where EGFR overexpression is
implicated. (2)
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Question 4

a) i) Briefly tabulate the late effects from radiotherapy that you might expect to find in a 30
year old survivor of medulloblastoma, who was treated at the age of 6 years with
craniospinal radiotherapy and cisplatin-based chemotherapy. (5)
ii) The patient above is seen by you and is complaining of feeling extremely tired and
weak. Her carers say that she was previously well but has been unable to get out of
bed for several months. She has no other symptoms other than amenorrhoea. She is
on no medication. On examination, she is listless and dull, with very dry skin and
thinning hair, and bradycardia. She has no papilloedema. Neurological testing shows
mild cerebellar signs(present since treatment) but no localising signs. She is generally
weak. What tests would you order? (4)

b) In Clinical trials
i) Tabulate the levels of evidence for therapy from strongest to weakest? (3)
ii) Describe the different phases of Clinical studies used to establish the highest level of
evidence. (6)

c) i) What are the primary goals of clinical practice and clinical research? Are they the
same? (3)
ii) What 2 factors might negatively impact on a physicians judgement in the ethical
conduct of a clinical practice? (2)
iii) List 2 positive influences on the ethical conduct of clinical practice. (2)
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5




FC Rad Onc(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the
College of Radiation Oncologists of South Africa

18 March 2014
Paper 2 Radiation and Medical Oncology (3 hours)

All questions to be answered. Each question to be answered in a separate book (or books if more than one is required
for the one answer)

Question 1

a) A 36-year-old female primigravida is 20 weeks pregnant. She presents with a >5cm mass
in her left breast.
i) Write short notes on the diagnosis and work-up of this patient. (3)
ii) The core biopsy confirms a infiltrating ductal carcinoma ER 20%, PR 10%, Her-2-neu
1+. Tabulate the role of surgery, chemotherapy, radiation and hormonal therapy in this
patient. (3)

b) i) A 35-year old female presents with a 6cm mass supero-lateral (R) breast. MMG shows
micro-calcifications. FNA malignant cells. Trucut biopsy repeated 8 times all show
DCIS High Grade. Her mother also had High Grade Ca Mamma. Write short notes on
the management of this patient. (5)
ii) A skin sparing mastectomy with immediate reconstruction was done by this patients
surgeon. DCIS was up to the surgical margins. What further treatment would be
indicated for this patient and motivate why? (2)
iii) This patient tested positive for the BRCA2 mutation. What would you advise her? (2)

c) Tabulate adjuvant fractionation schedules for breast radiation. What are the indications for
the different scheduling options and motivate your decisions? (5)


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d) A patient with breast cancer presents with metastases to thoracic vertebrae with pain, no
neurological fallout. ER 90%. PR 80%. Her-2-neu (1+). No other mets. The patient is post
menopausal, T2N1M1 (bone). ECOG 2 due to pain. What would be your choice of treatment
for this patient and motivate? (5)
[25]
Question 2

a) A 39-year-old female with a molar pregnancy has an evacuation.
i) How quickly do you expect the Beta hCG levels to disappear? (1)
ii) At that time the Beta hCG level is still 110 000 and your speculum evaluation and CT
thorax give no proof of vaginal mets or lung mets. Sonar abdomen shows no further
mass in uterus. Write short notes on your treatment for this patient including drugs and
doses and what would your follow-up of the Beta hCG entail. (6)

b) i) Tabulate indications for adjuvant irradiation St I and II Endometrial carcinoma. (2)
ii) What form of radiation would be used in St I or II Endometrial carcinoma? (1)
iii) Write short notes on the adjuvant treatment of St III and IV Endometrial carcinoma.(2)
iv) Tabulate the surgical approach indicated for Endometrial carcinoma. (3)

c) A 35-year-old patient with cancer of the vulva T2N2M0 and HIV (+), CD4 = 300 on anti-
retroviral therapy. ECOG 1.
i) What does this staging mean? (1)
ii) Make short notes about the treatment modalities you would use for this patient. (3)
iii) Tabulate the long term side effects of the treatment you would discuss with your patient.
(2)
iv) Tabulate which patients should receive adjuvant post-op radiation. (3)
v) What total dose would you prescribe adjuvant? (1)
[25]
Question 3

Head and Neck Cancers
a) Epidemiology
What is the most common histological type of head and neck (H&N) cancer? (1)

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b) Etiology and risk factors
i) What are the major risk factors of H&N cancer? (4)
ii) What is the EGFR in HNSCC (H&N Squamous cell carcinoma)? (1)
iii) Which virus is associated with nasopharyngeal non-keratinising and undifferentiated
cancer? (1)

c) Patient with cancer of tonsil T3N1M0
i) Explain what does this mean. (3)
ii) Can patients with an early stage H&N cancer be clinically observed? (1)
iii) Which patients should receive surgery as first-line therapy? (1)
iv) What is a classical radical neck dissection? (1)
v) Is there a role for surgery after radiation or chemo-radiation therapy? (1)
vi) What is the major advantage of radiation therapy in H&N cancer? (1)
vii) What is the major advantage of IMRT (intensity-modulated radiation therapy)? (1)
viii) Is there any advantage to using accelerated fraction radio-therapy versus single
fraction radio-therapy? (1)
ix) What is the standard dose in H&N cancer? (1)
x) What are common side effects of radiation to the H&N? (1)
xi) What is the standard regimen for concomitant chemotherapy for H&N cancer? (3)
xii) Give neo-adjuvant chemotherapy protocol for H&N cancers with doses. (3)
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Question 4

Oesophageal Cancer
a) What is T3N2M0 cancer of the oesophagus? (3)

b) Work-up and diagnosis
i) What tests should be ordered? (3)
ii) What is the pathology? (1)




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c) Treatment - First-Line
i) What is the treatment of patients with high-grade dysplasia (stage 0)? (1)
ii) What is the treatment of patients with early stage, node-negative disease (stage1)?(2)
iii) What are the treatment options for patients with locally advanced, resectable disease?
Give doses. (4)
iv) What is the treatment for patients with locally advanced, unresectable disease? (1)
v) What is the treatment for patients with stage IV disease? (3)
vi) What are treatment options for elderly patients with poor performance status? (3)
vii) How should patients who have received therapy for loco-regional disease be
monitored? (1)

(d) Treatment - Recurrent Disease
i) How is recurrent disease treated? (3)
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9



FC Rad Onc(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Part I Examination for the Fellowship of the
College of Radiation Oncologists of South Africa

19 March 2014
Paper 3 Radiation and Medical Oncology (3 hours)

All questions to be answered. Each question to be answered in a separate book (or books if more than one is required
for the one answer)

Question 1

a) Tabulate the indications for and the doses of irradiation in the treatment of low grade Non-
Hodgkins Lymphomas. (5)

b) A 70-year-old male, ECOG I, presents with a T2bNxM0, Gr II transitional cell carcinoma of
the bladder. He refuses radical surgery. Write short notes on an alternative curative
approach. (5)

c) A 45-year-old female presents with a large mass of the maxillary antrum. Biopsy shows a
Plasmacytoma. She is HIV negative. Write short notes on the subsequent management of
this patient. (5)

d) A 25-year-old male presents with a painless mass in his left testis, back ache and
progressive shortness of breath. Hormonal markers confirmed raised Alpha Feto Protein,
Beta-HCG levels.
i) What is the diagnosis and stage of this patient? (1)
ii) Which staging AND baseline investigations would you perform prior to treatment? (2)
iii) The first-line chemotherapy regimen you would prescribe with dosages used. (3)
iv) The most common and dose-limiting side-effects of each drug. (4)
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Question 2

a) A 68-year-old gentleman presenting with cough, dyspnoea and chest pain underwent
contrast enhanced chest and upper abdomen CT scanning followed by a bronchoscopy.
He was eventually diagnosed with Stage IIIA non-small cell (squamous cell) cancer of the
right upper lung lobe. He does not have serious co-morbidities, has weight loss of <5%
and PS of 1. Which are potential advantages of MRI over CT in lung cancer? (1.5)

b) Which lymph node stations could be assessed with extended cervical mediastinoscopy?
(3.5)

c) Define all possible T, N, and M combinations for Stage III A non-small (squamous) cell
cancer of the lung. (3)

d) Discuss role of surgery in the treatment of Stage IIIA non-small cell lung cancer, especially
pN2 . (2)

e) Describe how induction (neoadjuvant) chemotherapy followed by radiotherapy/
radiochemotherapy vs exclusive concurrent radiochemotherapy impact on both
locoregional tumor control and distant (microscopic) metastasis control. (4)

f) Discuss whether consolidation (maintenance) chemotherapy or targeted therapy offers
advantage if given after concurrent radiochemotherapy in stage III non-small cell lung
cancer. (2)

g) Indicate the preferred sequencing of combined radiation therapy and chemotherapy in this
case. (2)

h) Indicate the preferred radiation therapy dose (using standard fractionation) in this case.
(2)

i) Discuss possible chemotherapy administration scheduling in this case. (1.5)


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j) Discuss principal acute, high-grade, treatment-related toxicity expected to occur in this
case. (1.5)

k) Which Mean Lung Dose (MLD) and V20 values as dose constraints are usually used in
Stage III non-small cell lung cancer with/without concurrent chemotherapy? (2)
[25]

Question 3

a) Using recursive partitioning analysis, patients with malignant gliomas are divided into
different classes. Tabulate the different classes and the prognostic factors that define
these classes. (5)

b) A 23-year-old unmarried man is referred with a biopsy proven pure germinoma confined
to the pineal region. Write short notes on the treatment of this patient. (5)

c) A 4-year-old girl with a stage III nephroblastoma, favourable histology, is referred after
chemotherapy and complete surgery. Write short notes on the scheduling of the
radiotherapy, the radiation fields and dose of radiation. (5)

d) Tabulate the late effects of the radiation in this child. (5)

e) i) Write short notes on the indications for irradiation for the treatment of keloids. (2)
ii) Which cells are targeted by the irradiation? (1)
iii) Write short notes on the target volume, scheduling and total dose of irradiation in the
treatment of keloids. (2)
[25]
Question 4

a) Tabulate the uses of radio-active iodine in thyroid disease. (5)
b) Write short notes on
i) The action of and indications for Imiquimod (Aldara). (1)
ii) Nevoid basal cell carcinoma syndrome. (2)
iii) The M classification in the TNM staging for malignant melanoma. (2)
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c) Tabulate the side effects of
i) Dacarbazine.
Bevacizumab.
Actinomycin D. (4)
ii) In the case of extravasation of Etoposide, what measures should be taken
immediately? (1)

d) A 50-year-old male presents with a Dermatofibrosarcoma protuberans on his left anterior
thoracic wall. The tumor measures 7x8x2cm on MRI. Write short notes on the short and
long term management of this patient. (5)

e) Tabulate the guidelines for Limb Sparing Surgery in the treatment of osteosarcoma. (5)
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