BoardVitals is excited to announce our new Medical Oncology questions bank targeted to the ABIM Oncology Certification Exam. Over the past year, we have been hard at work partnering with world class Oncologists to bring you the best ABIM Oncology board review questions available.
Here are two sample questions taken from the BoardVitals Hem/Onc question bank.
Ms. FS is a 66 year old woman who has been undergoing annual lung cancer screening for a 30 pack-year history of smoking cigarettes. She feels well and quit smoking 10 years ago. Her last low-dose CT scan of the chest showed a 4cm right upper lobe lesion. A transthoracic fine needle aspiration confirms the diagnosis of non-small cell lung cancer with adenocarcinoma histology. Positron emission test (PET) scan reveals fludeoxyglucose (FDG) intensity localized only to the right upper lobe. She is referred for pulmonary function testing the results of which are normal. In addition to complete excision of the tumor via segmentectomy or wedge resection which of the following has the greatest indication as part of her evaluation.
- MRI of the brain
- Molecular testing on the surgical specimen
- No further evaluation is indicated until surgical pathology can be reviewed
This patient likely has a localized, stage I non-small cell lung cancer. It is paramount to perform appropriate pathologic staging in this setting which includes surgical resection of the lesion by a thoracic surgeon and a mediastinoscopy to evaluate the mediastinal lymph nodes. Mediastinoscopy can be performed either prior to or at the time of surgery and has been shown to be superior to CT and PET scan in determining presence of regional disease1–3.
Imaging of the brain with MRI to rule out asymptomatic brain metastases is indicated in patients with stage II, III, and IV disease4. This patient’s lesion is a T2a (3-5 cm) and without lymphadenopathy on imaging, would lead to stage IB so brain imaging is not indicated in the absence of symptoms.
The role for molecular testing in localized and regional non-small cell lung cancer is uncertain. In this scenario, the most important aspect to management is appropriate surgical staging.
- Tournoy, K. G. et al. Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study. Thorax 62, 696–701 (2007).
- Gonzalez-Stawinski, G. V. et al. A comparative analysis of positron emission tomography and mediastinoscopy in staging non-small cell lung cancer. J. Thorac. Cardiovasc. Surg. 126, 1900–1905 (2003).
- Patterson, G. A. et al. A prospective evaluation of magnetic resonance imaging, computed tomography, and mediastinoscopy in the preoperative assessment of mediastinal node status in bronchogenic carcinoma. J. Thorac. Cardiovasc. Surg. 94, 679–684 (1987).
- Mayr, N. A., Hussey, D. H. & Yuh, W. T. Cost-effectiveness of high-contrast-dose MR screening of asymptomatic brain metastasis. AJNR Am. J. Neuroradiol. 16, 215–217 (1995).
Mr. JW is a 50 year old gentleman with newly diagnosed advanced non-small cell lung cancer with adenocarcinoma history with confirmed involvement of the right upper lung and L5 vertebrae and several fludeoxyglucose (FDG) avid lesions in the liver. He is in good health and a life-long never smoker. You discuss molecular testing with him to determine the best next treatment option. What percentage of never-smokers with adenocarcinoma histology will have a targetable driver mutation such as epidermal growth factor receptor (EGFR) or Anaplastic Lymphoma Receptor Tyrosine Kinase (ALK) fusion present?
- Less than 5 %
- More than 95%
- Subramanian, J. & Govindan, R. Molecular profile of lung cancer in never smokers. Eur. J. Cancer Suppl. 11, 248–253 (2013).
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Best of luck with the upcoming exam!